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TREATISE
PNEUMONIA OF CHILDREN
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fV-e^'C
y
By M. M.^JULLIET and BARTHEZ,
HOSPITAL INTERNES, MEMBERS OF THE ANATOMICAL SOCIETY AT PARIS.
Duo sunt prrrcipui medicinal cardines, Ratio et Observatlo: Observatio tamcn
est filius ad quod dingi dcbent modicorum ratiocinia.— Baglivi.
TRANSLATED FROM THE FRENCH
By S . PARKMAN, M . D . ,
FELLOW OF THE MASSACHUSETTS MEDICAL SOCIETY, AND MEMBER OF THE
BOSTON SOCIETY FOR MEDICAL IMPROVEMENT.
PHILADELPHIA:
CAREY & HART
1841.
w
IU1
£■2
PREFACE OF THE AUTHORS
If we examine most of the treatises, which have been published
upon the diseases of children, we shall find the authors to have
attempted a description of those peculiar to childhood, rather than
of the common diseases of humanity, as influenced by that age.
We shall find, in their works, many dissertations upon certain
symptoms created with morbid entities, or up>n certain lesions,
which, by their rarity, attract the attention of all observers, but few
descriptions of the diseases which a daily practice presents.
Within a few years, however, authors have begun to study the
affections of children with particular reference to their pathology.
Numerous observations, and interesting memoirs, have been pub-
lished in different periodical collections; young physicians have
taken the subject for their inaugural dissertations. But from so
vast a field, all has not yet been reaped ; many important truths,
scattered here and there, have remained lost for want of being
incorporated with the body of science. A good book upon the dis-
eases of children is yet to be written. Far from us the idea of pre-
tending to undertake, at the present day, so great a labour. We
leave it to hands more skilful and experienced than ours. But
desirous of walking in the traces of those, who have preceded us,
and of profiting by the advantages of our situation, we have thought
to do something useful in studying this important part of pathology.
We purpose, (if this undertaking be favourably received,) to pub-
lish a series of monographs upon the different diseases of childhood.
A part of our material is already collected, but we wish to confirm,
by new observations, the ideas we at present entertain.
Among the diseases of this age, those of the chest are, without
doubt, both the most important, and the most numerous. We
commence therefore with them. These present researches upon
pneumonia will form the first part of a series upon the thoracic
affections.
Before entering upon our labour, we ought to say a few words
upon the method we have prescribed to ourselves in the perform-
ance of our undertaking, in order that the reader may appreciate
the degree of confidence to be placed in our assertions. Situated
VI PREFACE.
hs internes at the hospital for sick children, we have collected a
great number of facts. We have, particularly in the latter months
of the year, taken observations upon all the patients admitted into
the wards for acute diseases. Among these observations there are
sixty pneumonias, the analysis of which forms the basis of this
work. We might have operated upon a much greater number of
facts, but we have preferred to content ourselves with the analysis
only of those collected after a rigorous and continued examination
of the chests of children in the normal state. Being then enabled
to appreciate perfectly the comparative resonance of the different
parts of the thorax, we can count upon the exactitude of our
pathological researches. 1 Each particular fact has been collected
with all possible care ; the autopsies have been made with the
greatest detail, and the alterations have been minutely described at
the moment of the examinations. Our observations being col-
lected, we have decomposed them into their different elements, in
order to class, into as many distinct tables, the causes, symptoms,
pathology, &c. ; from each of these tables we have deduced propo-
sitions, the developement of which forms the base of this work. If
we have thought ourselves obliged to proceed with rigour, in the
analysis of our observations, if the numerical method has always
served us as a guide, we will aver, that we have avoided, as much
as possible, the filling our pages with figures and observations,
which would have rendered their reading both irksome and labo-
rious ; we have rather preferred to postpone, till the end of the
work, both the numerical tables and the observations, as vouchers
destined to prove the assertions which we have advanced.
We have not contented ourselves with giving merely the result
of our own experience, but have read and meditated upon the
works of authors, who have preceded us, and we have taken the
care to indicate the points, where their observations confirm ours,
as well as where they are at variance.
We would not terminate this preface, without tendering our
thanks to our masters, Messrs. Bandelocque and Bouneau, for the
wise counsels given, and the affectionate goodness always mani-
fested to us.
1 The study of the normal state of the child's chest will form the subject
of a separate monograph.
PNEUMONIA OF CHILDREN.
CHAPTER I.
HISTORY.
No where among- the ancients, (as remarks M. Leger, 1 ) do we
find a description of the pneumonia of children : they hardly men-
tion it, and if Stoll, Sydenham, Merten, Rosen, &c, say a few
words upon it, it is only when supervening in the course of the
eruptive fevers.
In 1823 appeared the first monograph, upon the pneumonia of
children, a faw years after the discovery of auscultation, without
the aid of which its history could not have heen given with success.
M. Leger gave to the disease, he was the first to describe, the name
of latent, a name deserved before his researches, but which it no
longer merits, since, at present, its diagnosis is among the things
certain.
M. Leger, after a careful examination of the causes, establishes
the following divisions :
1. A latent acute pneumonia, with symptoms more or less well
defined.
2. An acute pneumonia, without the usual diagnostic signs,
without cough, dyspnoea, &c, but on the contrary simulating some
other affection, not of the chest, or a meningitis.
3. A chronic pneumonia consecutive to an acute, or primitively
chronic ; and lastly, a pneumonia after measles. Twenty-eight
observations terminate this dissertation, being divided into four
series, after the divisions of the author; the greater part of the
cases were in children, aged from two to four years.
This thesis, although very remarkable, leaves many wants to
be supplied, many assertions to be corrected. The symptoms,
principally the stethoscopic signs, are indicated rather loosely;
many are passed over in silence ; the pathological anatomy is very
incompletely treated ; the divisions are too multiplied, and the ob-
servations taken with little care.
After M. Leger, M. Lenerx, 2 in an inaugural dissertation, enti-
tled, "The pneumonia of children compared with that of old men,"
' Thesis, 1S23, No. 49. 4 Thesis, 1825.
16— a ril 1*
6 RILLIET AND BARTIIEZ ON PNEUMONIA OP CHILDREN.
spoke of the mamellonated hepatisation peculiar to that organ. He
described the granulations of vesicular pneumonia as like the
tubercular, and he attributed them to chronic bronchitis. His
thesis, although voluminous, was not equal to that of M. Leger,
and, without any greater detail, contained a greater number of
errors.
M. Leger had laid no great stress on a particular form of hepa-
tisation, as frequent in children, although he mentioned it under the
name of partial splenisation. Many pathologists sought to repair
this oversight : thus in 1828, M. Berton 1 drew the attention of
observers to the lobular form presented by this affection in chil-
dren. He described its duration, the incertitude of the symptoms,
insisted strongly upon the frequency of the termination by pulmo-
nary abcess, and endeavoured to establish the diagnosis, between
tubercular phthisis and lobular pneumonia.
M. Burnet published, in the Journal Hebdomadaire, (July, 1833.)
some researches on this subject, and laid down the following pro-
positions.
1. The non-complication of pleurisy :
2. The possibility of cure by induration.
3. Its attacking indifferently all parts of the lung.
4. The non-termination by suppuration.
The thirteen observations, appended to this memoir, leave much
to be desired ; most of them are deficient in detail, the auscultation
incomplete, and the general symptoms and progress of the disease
very superficially described.
One year later, M. de la Berge, 2 in a memoir based upon detailed
observations, attempted a complete history of lobular pneumonia.
He divided the disease into two periods — the sthenic, of short, and
the asthenic, of longer duration. According to him, the treatment
should be much influenced by these periods. The precision and
exactitude of the descriptions of the morbid alterations of the lung
render the pathological anatomy the most valuable part of this
work.
Of the five observations terminating this memoir, three only are
examples of simple lobular pneumonia, and, in these three, the dis-
ease is very limited, (seven or eight points only). Of the two
others, there is a pneumonia of an entire lobe in the one and a
pleuritic effusion in the other.
About this time, Dr. Gerhard published in the American Journal
of Medical Science, (August and November, 1834,) some quite in-
teresting remarks upon the pneumonia of children.
He divides his patients into two classes, those over, and those
under, six years of age. He proves that, in the first class, pneu-
monia, taking place in otherwise full health, is not a grave affcc-
1 Thesis, 1828, No. 64.
* Journal Hebdomadaire, 1834, p. 414.
HISTORY. /
lion : in forty of his patients, only one died. He describes with
care the symptoms, and discusses the influence of treatment.
In the second part of his memoir, he treats of pneumonia in
children from two to six years of age, he demonstrates that in these
the disease is never developed in perfect health ; he insists upon the
lobular form of the hepatisation and dwells upon the modification
of the respiratory sound, and, after a careful description of the ana-
tomical lesions, he finishes with a few words upon treatment.
His work, fruit of an attentive observation, and based upon an
analysis of facts, is without contradiction the most valuable yet
published. The author, nevertheless, treating exclusively of pneu-
monia when perfectly evident, has neglected its study, when the
diagnosis, being more obscure, requires, in consequence, all the at-
tention of the practitioner. Having laboured in the same field of
observation, we have necessarily arrived at similar results, but we
have thought ourselves called upon to modify some of his asser-
tions, as well as to supply some of his deficiences.
M. Roudin, 1 in some researches upon the complications of mea-
sles, presented some remarks upon pneumonia. His observations
are upon ten children from two to seven years of age. and offer
nothing not contained in preceding publications. But we cannot
pass in silence a very remarkable omission in this memoir ; the
author has neglected entirely to notice the existence of any peculi-
arity in the form of the hepatisation, not even mentioning lobular
pneumonia.
M. Rufz, 2 has given, nearly verbatim, the memoir of Mr. Ger-
hard, to the composition of which he had assisted, in analysing a
part of the cases.
M. Berton, in his treatise upon the diseases of children, has add-
ed nothing to the ideas already advanced in his inaugural disserta-
tion.
M. Hourmann, 3 in a communication made to the Medical So-
ciety of Paris, described succinctly the pneumonia of children from
two to four years of age. He states, from six autopsies, that the
lobular form is far from being as common, as is usually supposed ;
he regards bronchial respiration as normal in children, disputes the
utility of percussion, and terminates with an observation of reco-
very in a child, of two years, treated by repeated venesection,
about a pound of blood having been taken.
Although we are noticing only works upon children from two
to fifteen years of age, we cannot pass in silence a very interesting
memoir, upon the pneumonia of infants, occupying one hundred
and fifty pages in the work, just published by M. Valleix. 4 This is
the result of an analysis of fifteen observations; an analysis made
1 Thesis, 1835, p. 91.
2 Journal rles Connoissances Medico-Chirurgicales, 1835, p. 10K
3 Revue Medicalc, April, 1835, p. 137.
* Cliniqu.e des Maladies des Enfans Nouveau-nes, 1Su8.
O RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN-
wi;h all the rigour of the numerical method. There are only three
cases of simple pneumonia; in the others, it complicated other
affections. The disease commenced by febrile agitation, heat, and
acceleration of the pulse, followed by cough, dyspnoea, subcrepi-
tous rale, bronchial respiration, and flatness on percussion com-
mencing at the base of the lung.
The constitutional symptoms disappeared after a day or two, and
were entirely wanting in the cases supervening on oedema.
After death, the hepatisation occupied the two lungs in the great
majority of the cases. Ordinarily more marked in the right, than
leftside, more frequently presenting the lobar than the lobular form ;
the morbid tissue was always very hard and smooth upon incision.
After attentively reading all these monographs, we see that none
except that of M. Leger, .presents a complete picture of the pneu-
monia of children, while some treat only of the lobular pneumonia
and of that variety revealed only by obscure symptoms ; others in
examining only the disease, when idiopathic, neglect entirely those
numerous and important instances where it complicates other
diseases.
CHAPTER II.
PATHOLOGICAL ANATOMY.
In the study of the anatomical lesions, authors have not endea-
voured to establish the connections between the different species
of the pneumonias of children ; on the contrary, they have given
us descriptions of each individual species, without attempting their
union under one and the same head, as they would seem to require.
We think also, they have too much neglected the examination of
those alterations of the respiratory apparatus, which complicate
pneumonia.
To present a complete picture of these morbid appearances, we
shall describe each kind separately, pointing out as far as possible,
its nature, and thus treal, in as many distinct paragraphs of vesi-
cular pneumonia or bronchitis, lobular pneumonia, lobar 1 pneu-
monia, of the state of carnification, and finish with a few words
upon the disease after it has become chronic. We shall then study
the alterations of the bronchial tubes, dwelling particularly upon
vesicular bronchitis and enlargement of the bronchi.
We shall endeavour, in each of these articles, to establish the
connections between these divers alterations,-and finish this chap-
1 The term lobar pneumonia will undoubtedly explain itself as given to
the disease, invading the whole or part of a lobe, as in the adult. (P.)
PATHOLOGICAL ANATOMY. »
ter by a succinct account of the concurrent alterations of other
organs.
Vesicular Pneumonia.
Trie lung, externally, is flaccid and soft, collapsing, more or less,
in proportion to the extent of disease. Upon incision, it presents a
number of granulations of the size of a millet seed, of a gray colour
bordering: upon the yellow. At first sight, these might be mistaken
for crude miliary tubercles disseminated through the lung, as we
often see them in children : but a more.careful examination shows
a great difference, both in their physical qualities and their nature.
Tubercles form full and solid bodies : the granulations of pneu-
monia contain a liquid. Thus, upon incision, some tubercles,
divided by the knife, present their cut surface on a level with that
of the pulmonary tissue, while others, escaping before its edge, pre-
serve their globular forms. These latter upon incision present the
usual appearance of tubercle. The granulations of pneumonia, on
the contrary, collapse in giving immediate issue to a drop of puri-
form liquid, and those which have escaped the knife remain whole
and spherical.
If these latter be opened with the point of an instrument, there
escapes the same puriform liquid, and in the centre we discover,
though often with difficulty, a small depressed point, departing
from which, we were, in one case, enabled to trace a small canal.
a few lines in length, with a smooth internal surface, which was
doubtless a minutebronchial ramification. There is nothing; com-
mon then to these two alterations, save their form, general disposi-
tion and colour.
From this description it appears probable, that the disease is con-
fined to the extremities of the bronchial tubes, and that a certain
number of the pulmonary vesicles, becoming inflamed separately,
are filled with this puriform liquid, and dilated without any in
flammatory participation of the surrounding cellular tissue. Doubt-
less, this appearance of the lesion confined to the pulmonary vesi-
cle Ins originated the name, vesicular pneumonia ; but perhaps
this appellation is improper, since the inflammation is confined to
a sing-le element of the pulmonary tissue ; we would therefore pre-
fer to call the disease, vesicular bronchitis.
If it happen, that many vesicles, in the vicinity of each other,
are affected, the connecting tissue may participate in the disease,
from which results a little mass, sometimes attaining the size of a
lentil, presenting, on incision, several of the granulations, or seve-
ral of the depressed points, which appearance, except this modifica-
tion from the granulations, is the lobular pneumonia to be presently
descrihed. There in fact exists, in such a case, vesicular bron-
chitis surrounded by lobular pneumonia.
In other instances, the pulmonary tissue, surrounding the dilated
10 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN-
vesicles, is evidently and generally hepatised, and then we have
vesicular bronchitis surrounded by lobar pneumonia.
The bronchi, leading to the diseased portion of the lung, are
sometimes dilated, sometimes healthy ; the former of which condi-
tions will be fully noticed in a further part of this work. ,
Lobular Pneumonia.
Lobular pneumonia is an inflammation occupying one or more
isolated lobules. It has been described under the names, mamel-
lonated, partial, disseminated. Its frequency and its gravity make
it deserving of an attentive examination.
Externally, the lung is usually soft and flaccid, of a grayish rose
colour, more or less deep, presenting scattered spots of a violet red,
generally clearly circumscribed, projecting, solid to the touch, and
not collapsing like the surrounding portions of the lung. These
spots, usually circular, sometimes elongated, especially from above
downwards, are chiefly situated at the posterior border of the lung,
but they are found, also, in all parts; sometimes they are absent,
and nothing abnormal is visible, but the finger detects the presence
of nodosities more or less deeply imbedded in the tissue.
Upon incision, we find the lung marbled, by a rosy gray, and
a deep violet red colour; the exterior red spots correspond to the
deep-coloured parts of the interior; and these spots, as well as the
others below the surface, form nodules of engorgement, presenting
the characters of ordinary hepatisation, viz. smooth to the knife,
granulated upon tearing, easily penetrated by the finger, and sink-
ing in water. But to establish this latter characteristic, it is neces-
sary to isolate perfectly the diseased portion, and to select espe-
cially the centre. Upon prrssure, there is little or no crepitation ;
and there is exuded a sanious liquid, with small bubbles of air, but
if we be careful to press only the centre, the liquid issues without
the air, as in common lobar pneumonia.
We meet with this species of pneumonia at the first, second, and
third degrees.
Then, upon incision, we have the pulmonary tissue marbled, of
a red or rosy gray, the red parts more or less regularly limited, a
little less resistant than the surrounding tissue, still swimming on
the surface, with whatever care we rnayisolate them, exuding upon
pressure a liquid entirely penetrated with air, and still crepitating
under the finger. This is the first degree,.
The second we have already described.
The third presents itself under so insidious a form, as, without
particular attention, to be easily overlooked at the autopsy. And
as, during life, the physical signs arc frequently absent, it "is easily
Conceivable that the disease may be undiscovered, and considerable
uncertainty be thrown upon I he cause of death.
Thus, when the points of inflammation are small in size and
have passed entirely from the second to the third degree, the dis-
PATHOLOGICAL ANATOMY. "
eased tissue becomes grayish, and presents very little difference from
the surrounding portions. The reader will therefore easily con-
ceive, that if it requires a careful attention to establish the exist-
ence of a lobular pneumonia at the second degree, how much more
is necessary to recognise it when arrived at the third stage, where
the peculiar colour, the most common of the marks, has disap-
peared.
But if we pay proper attention, we cannot fail of remarking, that
in the track of the incision certain lobules are projecting, the vesi-
cles not collapsing as in the surrounding portions, and that pressure
in these lobules gives issue to a liquid, rather purulent than serous,
after which we may easily establish the existence of the other cha-
racteristic signs.
This description of the three stages of pneumonia, written with
the preparations before our eyes, and which is very nearly a conipend.
of the opinions of all the authors upon the subject, does not appear
to us, however, to give a perfect idea of the pathological anatomy
and the progress of the disease. We have thought that we have
observed two forms of the lobular pneumonia, the one perfectly
circumscribed, which we would call mamellonated, the other not
so clearly limited, to which we would give the name of partial. In
giving these names we would not be understood as thinking to
describe two distinct diseases ; we consider them only as two forms
of an identical affection, having a common origin, but a different
progress; finishing by presenting some modifications of the symp-
toms, and of which the partial is an intervening stage between the
lobular and the lobar pneumonia.
The mamellonated pneumonia forms a nodule of inflammation,
the colour and appearance of which contrasts strongly with the sur-
rounding tissue. It is a point of pneumonia perfectly limited,
thrown into the midst of a tissue nearly or quite healthy, and its
boundaries are clearly defined, even when the surrounding tex-
tures are engorged. It may even happen, as we have seen m one
subject presenting about a dozen of these nodules, that the boundary
is marked by a circle, or rather by a white resistant spherical cap-
sule, of about an eighth of a line in thickness, and presenting^
fibrous aspect. Usually, the line of demarcation, besides the
change of colour, is indicated by the collapse after an incision ot
all the surrounding parts.
The size of these nodules varies from a hemp-seed to a pigeon s
ecrcr- their border is generally regular, representing a sphere, or
some analogous figure, and their number varies from one in a lung
to twenty, thirty, or even more.
The partial pneumonia, on the contrary, is less well defined than
the mamellonated ; its circumference is insensibly confounded with
the surroun ling textures, without any distinct demarcation, either
bv change of colour or protuberance of the diseased part ; its vo-
lume often neater than in the mamellonated form, is, however,
sometimes the same : its form is not always regular, the inflamma-
12 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
tion extends itself in different directions, and is either every where
advanced to the second degree, or the centre is alone so, while the
circumference has only attained the first.
In this latter case it may happen, that a part of one nodule, still
at the first stage of inflammation, connects itself with several other
points of pneumonia, and we have the whole or the greater part of
a lobe inflamed and presenting the characteristics of the first and
second degree, scattered without any apparent order through its
substance.
Upon these considerations, we establish the two forms of lobular
pneumonia, one resulting from an inflammation of one or more
individual lobules, without any tendency to attack those adjacent ;
while the other is the consequence of an inflammation developed
in one group of lobules, gradually involving all the surrounding
ones. In the first case, the inflammation, if we may use the ex-
pression, is centripetal, concentrating itself in the lobules primitively
affected. While in the other it is centrifugal, tending to spread
and attack all around it.
Hence the explanation, why the mamellonated pneumonia may
suppurate and form an abcess, while the partial form tends to be-
come general or lobar. But that these are only modifications of
the same form of the disease, is proved by an observation which we
possess, where one side presented the mamellonated pneumonia at
the stage of suppuration, and the other the partial form tending to
become general.
In these two cases, the following is the state in which we find
the lung affected :
If the mamellonated pneumonia have passed into the stage of
suppuration and abscess, an incision presents to us little cavities,
in form and disposition answering to the lobular hepatization at
the second degree. Their volume" varies from that of a hemp-seed
to that of a large pea. These cavities are filled with pus. mingled
at times with clots of blood ; they communicate sometimes with
the bronchi, and at the point of entrance of the bronchus into the
cavity, the mucous membrane cuds abruptly, presenting the ap-
pearance of a solution of continuity, quite evident to the sight, and
shown by the formation of strips, if the caliber of the bronchus
admit of this method of examination. Many of these abcesses
however, do not communicate with a bronchus, but are surrounded
by it, in this manner proving that the interior of a bronchus was
not in these cases the point of departure of the inflammation.
We insist strongly upon this latter remark, because it is necessary
to distinguish carefully these abscesses, which are rare, from another
more frequent lesion, to be hereafter described, the dilatation of the
bronchial extremities. One character which will aid us in seek-
ing this distinction, is, that the parietes of the dilated cavitv are
smooth, polished, and gradually continuous into the bronchial tube
whilst in the abscess they present quite a different aspect, the bron-
chus being seen to open abruptly into the cavity.
PATHOLOGICAL ANATOMY.
13
If the lobular pneumonia, already become general, have passed
to the third degree, we observe it as entirely lobar, and an incision
presents an aspect which all will recognise from the foregoing
descriptions : those points which were at the first stage will have
reached the second, while those at the second will have attained
the third. The texture will be marbled, with a mingled red and
yellowish gray.
There is, however, a difference between a lobar pneumonia and
a partial pneumonia become general, which consists in the different
disposition in the lung at thedifferent stages of the disease. Thus,
in common lobar pneumonia, the disease, commencing usually at
the base of the lung, advances upwards ; and, whilst the base
passes to the second degree, the parts above are attacked in the
first, and thus in succession : while in the other case, the disease,
having commenced in distinct lobules, presents its different stages
scattered without order through the lung.
This consideration may serve to determine, in the dead subject,
if a pneumonia was primitively lobular or lobar; not universally,
however, as the pneumonia, in becoming general, may have re-
mained at the second decree, thus imitating perfectly one originally
lobar.
But even in this case, as in the preceding, we usually find in the
same lobe, or in the same or opposite lung, some distinct lobules,
inflamed in the second degree, constituting the remains of a defined
lobular pneumonia, cases which have hitherto been regarded as a
union of the lobar and lobular pneumonias, — added to all which, a
careful study of the symptoms during the patient's life-time, will
materially aid the diagnosis of the two lesions before us. 1
The anatomical proof of the existence of a lobar pneumonia is
much rarer in children than adults; for, in general, before five
years of age, idiopathic pneumonia seldom exists, and after that
age the disease is seldom fatal.
Nevertheless, in cases of death from some complication, we have
seen a sufficient number of such autopsies to convince us that the
lesion is the same at both these periods of life.
1 It may be well to mention here a form of pneumonia of children pointed
out by Ml de la Bergs, under the name of the marginal. It often happens
in reality, that we find hepatisation slight in extent, seated around the base
or on the anterior border of the lung ; these hepatisations perfectly resemble
ordinary inflammations in their pathological alterations, and physical cha-
racters. The circumstance of the seat and slight extent of the disease suf-
fice to attract attention. Its symptoms are inappreciable, and we may find
its cause in the feebleness of the child and the want of reaction in the pul-
monary organs; allowing those parts most distant from the centre of the
circulation to become engorged. For we are not to think that it is from an
excess of vitality that the lungs of children inflame— reasoning thus, the
lungs of old men should have"" the same attributes of superior vital force,
judging from the frequency of pneumonia ; besides, in children we ought to
observe it attack with preference the most vigorous and most healthy,
whereas the reverse is the more general rule.
14 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN-
To the distinction of some authors, founded upon the smooth
surface presented by an incision of the inflamed portion, we attach
no great importance ; since, even when the texture is smooth
under these circumstances, it is not the less granulated upon
tearing.
After this description of the different forms of the acute pneumo-
nia of children, we pause a moment to remark, that all these lesions
are only varieties of the same affection, without any special pecu-
liarity attached to either; since from one to the other there is but
a step, and since one can easily transform itself into the other.
In truth, commencing with the capillary bronchitis, of which we
shall soon speak in detail, we next arrive at the vesicular pneu-
monia, or rather bronchitis, which is an evident extension of the
first, and thence to the true lobular pneumonia, the transition state
being in those cases where the vesicular bronchitis is surrounded
by a lobular pneumonia. Besides, all the authors upon this latter
species of pneumonia have endeavoured to establish it as a conse-
quence of a bronchitis ; for this propagation of inflammation from
one tissue to another is easily conceivable, and by it alone we might
explain the development of lobular pneumonia. In reality, the
final bronchial ramifications, being independent one of the other,
we easily conceive how the inflammation propagates itself by iso-
lated lobules; and the whole, therefore, reduces itself to this, that
childhood, more than any age, is disposed to capillary bronchitis,
or to the affections consequent upon it; and having before shown
the passage of the lobular into the lobar pneumonia, we have com-
pleted the series of the pulmonary inflammations of children.
Beginning with capillary bronchitis, advancing to vesicular
bronchitis, to lobular, and finally lobar pneumonia, we find the
only difference between these diseases to be in the greater or less
extent of the inflammation.
We must, however, guard ourselves against too great a general-
isation of these ideas, involving, as a consequence, the opinion, that
in the child all the inflammations of the lung commence by the
capillary bronchitis, and pass successively through all the decrees
above described; it will be shown atalater period of this worL that
pathological anatomy, on the one hand, does not furnish the means
of positively recognising the existence of the bronchitis; while on
the other, in the greater number of pneumonias, especially the
lobar, the bronchitis is not of sufficient extent, and the constitu-
tional symptoms appear too suddenly to allow of the supposition of
this propagation of the inflammation from one tissue to the other.
We would only wish then to establish the existence of these va-
rieties, the small distance which separates them, and the easy trans-
migration of one to the other.
To complete, then, the description of our views upon the pneu-
monia of this age, it only remains to speak of two kinds of altera-
tion of the texture of the lung, distinct, and yet offering, perhaps'
PATHOLOGICAL ANATOMY. 15
some analogy one with the other : we refer to carnification of the
lung and chronic pneumonia.
Carnification.
The former of these alterations, though somewhat frequent, 1 has
never been described by authors, and is merely alluded to in a note
to the memoir of M. Rufz. The description, given by him, is how-
ever exact, and agrees perfectly with our observations.
The lung, in this state is, externally, collapsed, soft, and flaccid,
instead of full, hard, and resistant as in pneumonia. Its colour is
violet, marbled by white lines, disposed in losenges or squares, de-
fining the lobules, without any crepitation upon pressure.
An incision presents a texture of a red colour, smooth, resisting
the pressure of the finger, so as to be penetrable with considerable
difficulty ; exuding upon pressure a serous bloody liquid destitute
of air. Its appearance very like the close compact fibres of a mus-
cle has given it its name.
The .carnification occupies often the circumference of the base of
one of the lungs, being then marginal, or else some portion of a
lobe: the middle lobe is the only one we have seen entirely in-
vaded ; whilst at other times it affects the lobular form, appearing
in distinct and separate circumscribed masses.
From this we see that this lesion affects the peculiar seat of each
species of pneumonia, never, however, involving any considerable
quantity of lung. It exists besides in subjects presenting at the
same time the lobar and lobular pneumonias.
The first idea, presented to the mind by the examination of this
tissue, is the resemblance to a lung of a foetus which has not yet
respired; the vesicles of which have not yet dilated, under the
• thoracic expansion, to admit the air into their interior. Or we
might think them to have been obliterated by some disease, an in-
flammation perhaps, the engorgement having disappeared, without
leaving the vesicles the power of returning to their former state of
dilatation.
With these views, we might regard the carnification as a sort of
termination of pneumonia or as that disease in a chronic stage. In
fact we possess an observation which would justify this idea; it is
of a child, presenting for a long time the signs of a pneumonia of
the ri^ht side, and dying finally of the disease invading the left;
the autopsy showed a considerable carnification of the right lung,
at those points where the auscultation had previously established
the existence of a pneumonia.
Chronic Pneumonia.
Authors are by no means agreed upon what we ought to under-
1 See table of the Pathological Anatomy.
16 RILLIET AND BARTHEZ ON PNEUMONIA OP CHILDREN.
stand by the chronic pneumonia of children, and to show how con-
fused are their ideas upon this subject, it will be sufficient for the
reader to know, that some consider it very frequent, while others
regard it as very rare.
M. de la Berge speaks of the yellowish gray colour as marking
the change to the chronic state ; but we can regard this only as
indicative of the third stage of the disease in children, as is admitted
on all hands in the adult ; and we must have something besides
colour to characterise the passage to the chronic state.
We have never met with any lesion which might be regarded as
chronic pneumonia, unless it be the carnification just described:
we shall not attempt therefore any description of this affection.
Tubercles.
Tubercles, so common in youth, might naturally be expected to
present themselves frequently with the pneumonia of children, never-
theless they are very rare.' Our results agree perfectly with those
of Gerhard and Rufz, although we would not as yet agree with the
latter in the conclusion that measles ought not to be considered a
cause of tubercles : the question merits a separate attention and
does not form part of our subject.
We have observed tubercles in fifteen of forty-three autopsies.
In three cases they existed in other organs besides the lungs, in
the bronchial or mesenteric glands ; in the other cases their number
was small : they appeared to select the superior lobe ; and twice
we found them at the extremity of a dilated bronchus, and twice in
the centre of a lobular pneumonia.
Here terminate our remarks upon the pathological anatomy of
the pneumonia of children ; we shall refer hereafter 2 to the com-
parative frequency of each of these affections in the different ages ;
but we have thought it might be useful to connect with the pre-
ceding descriptions some account of many other alterations, which,
mingling their symptoms with those of 'the pneumonia, merit for
that reason a careful examination.
The Bronchial Tubes.
We have made the bronchi a subject of particular attention ■ we
have noted carefully their caliber, the colour, thickening, and'soft-
ening of their mucous membrane, as well as the liquids contained
in their cavities.
Caliber.— Most of the authors have spoken of the dilatation of
the bronchi, but without insisting sufficiently, we think upon this
lesion, which must be so frequent, since we have found it in one
» We would be understood not to speak of those more frequent cases where
the tubercles being the principal disease are complicated by pneumonia but
only of those instances where the pneumonia is the primitive lesion '
2 Vide table of Pathological Anatomy.
PATHOLOGICAL ANATOMY. 17
quarter of the cases terminating fatally. The dilatation of the
bronchi affects two forms, quite distinct and apparently the result
of the difference of seat ; the lesion is sometimes in their course,
and at others in their extremities.
In the first instance the scissors, instead of entangling themselves
in the walls of the bronchi, easily follow the smallest branches and
arrive immediately at the surface of the lung. Upon laying open
the bronchus in the whole of its length, we see it, from one of the
first divisions preserving throughout the same diameter, or even
perhaps insensibly increasing it. In some cases the dilatation, ap-
pearing suddenly at some point in strong contrast with the volnmn
of the bronchus from which it springs, continues so throughout the
whole extent. Sometimes the dilatation appears only in the smaller
bronchi, which have then but a slight though perceptible increase.
We have never seen the spindle-shaped form of dilatation in which
a bronchus dilates and contracts again almost immediately, in a
manner to simulate a small cavern.
Only two cases have presented a thickening of the walls of the
bronchus ; in one of these it was tripled, and might have been re-
garded as chronic with relation to the concomitant disease. The
dilatation sometimes has invaded a large part of the lung; in
other cases we observe it limited to a space not exceeding a small
egg-
In all the cases except one, the dilated bronchi were surrounded
by diseased tissue, either hepatisation or carnification ; in one
case we found only a vesicular emphysema without any inflamma-
tion.
If the bronchi be dilated in their extremities, the incision of the
lung presents a surface strewn with a number of little cavities,
communicating with each other, and with the bronchi of which
they appear the continuation.
The communication of one with the other is made through an
opening in a simple membranous partition, or by means of a cylin-
drical canal apparently a dilated bronchus, and which often fur-
nishes branches themselves involved in the same disease. It may
happen, however, that these channels of communication are yet in
the normal state.
The greater part of these cavities are surrounded by the lung,
but in some instances existing at the surface they are merely en-
closed by the pleura, forming externally a small protuberance, and
collapsing immediately upon puncture, in this manner simulating
emphysema. These little cavities contain the same liquid as the
bronchi, their parietes are smooth, thin, and lined by what is evi-
dently a continuation of the bronchial mucous membrane.
This is the alteration liable to be mistaken for the little abcesses
of lobular pneumonia, but we have already pointed out the diag-
nostic differences between the two.
We have now to decide if the dilatation of the bronchus be con-
sequent or precedent to inflammation of the parenchyma. Although
16— b ril 2
18 RILLIET AND BARTHEZ OX PNEUMONIA OF CHILDREN.
difficult of decision, it has seemed to us that the dilatation has either
commenced at the same time with the pneumonia, or been a va-
loped in its course, as by the physical signs we have never detect :d
any symptoms anterior to those of the pneumonia. Its formatioi
is, perhaps, entirely mechanical, from the sojourn of an abundant
mucous secretion in the bronchial tubes. A supposition streng h-
ened by the absence of any thickening of the parietes of the bron-
chial tubes thus affected.
Colour — Thickening — Softening.
The alterations of the mucous membrane, as demonstrating their
inflammatory state, merit a very peculiar attention.
We are not to think, however, that an inflammation can be as
easily demonstrated here as in the intestinal mucous membrane.
The* conditions of the two cases are widely different, for, 1st, th 3
simple section of the lung covers the mucous membrane with blood,
so as to require a careful washing, to arrive at proper conclusions
of the colour; and 2d, the bronchial tubes, becoming thinner and
more transparent in proportion as they become finer, allow the sub-
jacent tissue to impose its own colour upon that of their mucous
membrane.
. We are driven therefore to a careful examination of the appear-
ances furnished by the formation of strips ; now these strips
although easily obtained in bronchi of any size, are no longer so
when the caliber commences to lessen, even before it has become
capillary. In this case then, the tenuity of the vessel opposes it-
self to any elucidation, by this means, of the pathological anatomy.
Nevertheless we have thought ourselves justified in admitting
the existence of a capillary bronchitis, whenever we have found a
redness equally diffused in the mucous membrane in spite of a
different colouration of the subjacent tissue, and more especially
when the liquid in these bronchi was abundant.
We have established, yet but rarely, the softening and redness
of the mucous membrane by the aid of the formation of strips ; but
in the great majority of cases these lesions have escaped us, and
we are compelled to acknowledge that the existence of the capil-
lary bronchitis can seldom be proved by pathological anatomy.
Liquids in the Bronchi.
As yet these have not attracted any particular attention, and
although we have made them the subject of a particular study,
our examinations upon this point have been by no means com-
plete.
We find, however, noted in our observations the greater or less
abundance of these liquids, and the presence or absence of air in
them; we find it often remarked, also, that the mucus was grayish
thin, not viscous, puriform, or else the contrary, viscous, whitish'
PATHOLOGICAL ANATOMY.
19
purely mucous; and these remarks have assisted us in the explana-
tion of certain stethoscopic signs.
But we would have wished to have been able by more detailed
observations to determine the relations of the different species of
inflammations, the bronchial dilatation and the abundance of liquid,
with its consistence, its tenuity, and its mixture with air; we
would have wished to see if in the same lung the mucus were
more abundant where inflammation is seen to have existed, than
where, although the eye after death detects no alteration of the
tissue, auscultation has indicated the existence of rales during life;
if there may exist mucus in the bronchi without pneumonia or
capillary bronchitis, <fcc. To answer these questions, it would be
necessary to decide if the decubitus of the body upon the back de-
termine the gravitation of the fluids to that part. All these details, at
present left incomplete, will be the object of future study.
We may nevertheless endeavour to determine whether abund-
ance of mucus be a necessary proof of an inflammation of the
bronchi. Upon this subject we are of opinion, that a bronchitis
cannot be admitted unless we have the existence of the mucus;
that its presence, in any quantity, however great, by no means
establishes the bronchitis, for we have seen the fluid where it was
impossible to admit an existence of this latter, — a fact easily con-
ceivable, considering the great weakness of children, which prevents
the expectoration of the mucosities. and allows their accumulation
upon the surfaces normally secreting them.
Larynx — Trachea —Large Bronchi.
Inflammation of these organs in connection with pneumonia is
not frequent. We have twice seen erosions upon the inferior vocal
chords ; in one there had been measles with hoarseness, in the other
entire loss of the voice; inflammation of the large bronchi is very
rare, once only we have satisfied ourselves of its existence, we
therefore rest assured that if there is a bronchitis existent with the
pneumonia of children, it is always capillary.
Vesicular Emphysema.
To complete the series of the alterations, which we have met
complicating pneumonia, we must mention vesicular emphysema,
which we have sometimes observed.
It presented, usually, the following appearances. Occupying
especially the summit and the anterior border of the lung, the em-
physematous portions did not collapse upon the admission of air
into the chest ; they appeared of more than the ordinary thickness
of these parts, and extended towards, or even covered the corres-
ponding portions of, the opposite lung.
The lobules of the lung were protuberant, and the pulmonary
vesicles, more distinct than elsewhere, were unequally though
20 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN-
slightly dilated, being never seen larger than the head of a large
pin. We have never met with the appendices described by M.
Louis. The emphysematous portions felt between the fingers did
not appear thicker than the healthy tissue. The vesicles were per-
fectly transparent, and collapsed entirely upon puncture.
This alteration has appeared due, in some cases, to a rachitism ot
the chest, causing such a deformation as to compress the lung in
certain parts. We shall develope this idea in another work, of
which we have in part the materials.
Pleura.
Authors have said that pleurisy is rare in the child ; if by this they
mean, that pleurisy does not complicate pneumonia so generally as
in the adult, they are right ; but they are mistaken if they imagine
pleurisy to be in itself a rare disease in children ; since it is very
common to find in the pleura of this age traces of recent or old in-
flammations. Thus, in forty-three cases, we have found the pleurae
healthy only ten times. Nineteen times we have met ancient ad-
hesions more or less extensive, situated especially along the pos-
terior border of the lung. Sixteen 1 times we have found recent
adhesions not differing essentially from those in adults. Thus we
have met with redness, and vivid injection of the pleura, with yel-
lowish, soft, elastic, and at times tuberculous false membranes,
with gelatiniform adhesions infiltrated with serosity, or with lemon
coloured, clear, or flocculent serous effusions, and finally even with
effusions of a purulent nature.
Acute pleurisy has been thought especially rare in children from
two to five years, (Gerhard and Rufz) : but we have observed it in
a third of the cases at that age. It appears more frequent in females
than males, and has always coexisted with a lobar pneumonia, or
with the lobular form become general.
Bronchial Glands.
Often healthy, in other cases however, they were increased in
volume, softened, reddened, or of a paler hue. Sometimes they
had undergone tubercular degeneration, but in these the existence
of tubercles was almost constant in the lungs: and even in one case,
where one lung only contained tubercles, the glands of that side
were alone affected.
As to alterations existent in the organs of other functions their
description does not form a part of our subject, it will be sufficient
to indicate them, that their complication may be appreciated.
1 These numbers form a total of forty-five instead of forty-three, two of
the observations being doubled, from presenting recent, together with old
adhesions.
PATHOLOGICAL ANATOMY. 21
Pericardium.
Healthy in all our patients, containing from one half to three
spoonfuls of a lemon coloured serosity ; one subject, who had suc-
cumbed to hemorrhagic measles, presented ecchymosislunder the
fold of this membrane investing the heart; and another presented
an ecchymosis under the serous membrane lining the fibrous invest-
ment of that organ, the consequence of pressure from a rachitic
deformation of the chest.
Heart.
Always found in a normal state, both in volume and structure.
It contained often coagula, either black or fibrinous ; colourless
in the auricles, and sometimes in the right ventricle. In the case
of hemorrhagic measles, there were no where any coagula.
The lining membrane was always smooth, polished, and pale.
The valves, especially of the left side, presented, rather often, a
somewhat vivid redness, being thus tinged in one quarter of the
cases, sometimes on the right, sometimes on the left, and at other
times on both sides indiscriminately.
Brain.
Most generally the nervous system was healthy, with the excep-
tion of a subarachnoid infiltration, somewhat abundant, but neither
more so, nor more frequent than in the other diseases of children.
Once there was a general hardening of the substance of the
brain and spinal marrow ; but there had been an existence of
paraplegia, and the child showed some symptoms of asphyxia.
Digestive tube. — Stomach.
Seldom but slightly affected ; this viscus has presented the fol-
lowing alterations : —
Ten times softening of the mucous membrane of the grand cur-
vature: ought this to be regarded as cadaveric?
Redness, in different degrees, without softening or thickening,
to be regarded as a slight congestion, but not inflammation, five
times.
Once we found thickening, without injection; once ecchymosis;
once linear redness along the grand curvature, with softening and
superficial erosions: and, finally, in one case, after the injection of
a large quantity of Kermes mineral, we found vivid redness in the
small curvature, existing in large bands, small lines, or little points,
with ecchymosis, the softening having attacked indifferently the
red and the pale portions.
Small Intestine.
The lesions we have met in this organ are the following:— some
22 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
arborescent vessels or congestions more vivid than in the healthy-
state ; thrice a white softening of the mucous membrane in a con-
siderable extent ; nine times redness and softening in the patches
of Peyer ; once only any ulceration of these patches. Every one is
aware that the glands of Brunner appear in children generally very
protuberant under the mucous membrane, dotted, or reticulated
with black, without any actual morbid affection. We have, how-
ever, found them sometimes so red, soft, and swollen, as no longer
to be regarded in the normal state.
Large Intestine.
It is here that we find the most frequent complications of pneu-
monia. But we must remark, that inflammations of this organ,
together with those of the lungs, are, perhaps, the direases most
fatal to childhood.
The alterations may be classed as follows : —
1. Colitis, with redness, thickening, and softening.
2. Abnormal dilatation of the follicular orifices.
3. Colitis, advanced to ulceration, with or without false mem-
brane. These ulcerations have always appeared seated in the
follicles, more numerous at the end of the intestine, and never in
the caecum.
4. Softening, without notable change of colour, and with a nor-
mal thickness.
5. The easy separation of the mucous membrane from the sub-
jacent tissue, with or without redness.
6. Ecchymosis.
To give, in a fevr words, our conclusions, the digestive tube has
been the organ most frequently complicating by its affections the
pneumonia — hardly can we count nine cases where it was through-
out healthy. The greater part of these affections, especially of The
large intestine, was chronic, consequently antecedent to the pneu-
monia ; in proof of this, we have the fact that, in the great majo-
rity, the pneumonia developed itself in patients labouring under
some anterior malady. The other abdominal organs were either
healthy, or their slight alterations hardly deserve attention :— we
may merely remark, however, that in the case of hemorrhao-jc
measles, the kidneys presented numerous ecchymoscs, with thick-
ening of the mucous membrane of their pelves.
MODIFICATIONS OF THE RESPIRATORY SOUND. 23
CHAPTER III.
MODIFICATIONS OF THE RESPIRATORY SOUND.
The discovery of auscultation, so eminently useful in the thoracic
affections of adults, ought to render double service in the study of
these maladies in a younger age. In reality, during the first years
of life, the lung most often only betrays its diseases by those signs
which the physical examination reveals: deprived of this precious
aid to our investigation, we should be exposed every day to mis-
take, or to overlook the greater part of the diseases of the viscera
contained in the cavity of the chest: therefore ought we to pay a
particular attention to the numerous modifications of the respira-
tory murmur in this class of patients.
This subject has not yet received all the care it deserves: the
character of the rales, their seat and frequency, the changes of one
into another, and, above all, their respective diagnostic values, have
not yet been pointed out in a sufficiently clear and positive manner.
Let us see what the analysis of our facts furnishes upon this sub-
ject, in examining successively the sonorous, sibilant, mucous,
subcrepitous, and crepitous rales, the bronchial respiration, and the
natural respiration, when rude or obscure.
The sonorous and sibilant rales. — Their characters are the
same as in the adult, and they are, without doubt, the least im-
portant of all — their duration is usually very short, (two days at the
most:) they affect indifferently all parts of the chest, but never in-
volve it in its whole extent. We find them at different epochs, but
in a third of the cases (especially in the young subjects) before a
full declaration of the malady. They precede, therefore, the ap-
pearance of the bronchial respiration, but seldom immediately, for
usually we hear other rales before this latter manifests itself: in
the large number of cases they are intermingled with the mucous
crackles, and the sounds which replace them are very variable.
They present hardly any diagnostic value, except in patients from
two to five years, where the pneumonia usually commences with a
bronchitis, and where the sibilant rale is often the first symptom of
this latter affection. We deduce from this the practical consequence
that, in a child of two years, a sonorous or sibilant rale should
put the physician upon his guard against the ulterior development
of a pneumonia.
As to the producing cause, the inconstancy and short duration
of these tales have never allowed its discovery: we can, however,
say. that in no case where they have been present, have we been
able to discover, at the autopsy, in the corresponding part of the
Innff, any tumefaction of the mucous membrane of the smaller
bronchi.
24 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
The mucous rale.— This rale resembles that in the adult, and
does not present any varieties from age. Its bubbles, sometimes
large, under the form of a crackle, sometimes finer, approach, in
this latter case, the subcrepitous, with which it is easily con-
founded.
The mucous rule is heard usually both in inspiration and
expiration, in all parts of the chest, always behind, generally on
both sides, and sometimes in front. It presents itself at all the
various periods, at the commencement, a (ew days after, or at any
point in the course of the pneumonia.
We have remarked nothing constant in the alterations of the
respiratory murmur preceding or succeeding it: we have seen it,
however, succeed to a pure respiration rather oftener than to any
other species. Its duration has, in general, been very short. This
latter remark is especially true in children from two to five years,
for in those from five to ten its progress, sometimes irregular, has
been more constantly uniform, and its duration longer: it has ex-
isted throughout the whole of the disease, and when once its
presence has been established, it was rare that we did not find
it many days in succession in the same place, more or less ex-
fended. Seven times in thirty it was mingled with a bronchial
respiration, especially in children from two to five years: once
even it manifested itself at evening in a point where, on the morrow,
we found a bronchial respiration.
From what we have said, the value of this rale appears superior to
that of either of the other two : its great frequency, its persistence in
certain cases, and its frequent coexisting with, or preceding a tubal
respiration, render it a most precious means of diagnosis. It may,
therefore, sometimes be regarded as the generating rale of bronchial
respiration, (only, however, in cases from two to five years.) What
a difference from the mucous rale of adults, which is only indica-
tive of a simple catarrh !
The subcrepitous rale. — What we have said of the last rale will
apply, in part, to the subcrepitous, since, in a large number of
cases, the passage of one to the other is very difficult to seize.
Generally, it was heard in both the times of the respiration ; some-
times only in the inspiration, especially when accompanying the
bronchial sound : once only it existed in the expiration alone. Our
remarks upon this rale refer especially to children from two to
ten years, for from ten to fifteen we have observed it but five times.
It existed oftener on both sides than on one alone : in three quar-
ters of the cases to a greater extent at the base than elsewhere, but
we have heard it in all parts of the chest. When existent only on
one side, it was often mingled with a bronchial respiration : in the
young subjects, from two to five years, in half the cases where
heard, it appeared in points where the bronchial respiration after-
wards developed itself; so that it may be regarded as one of its
generating rales. Observe, to strengthen this remark, that it was
precisely in those cases where we had ausculted the patients from
MODIFICATIONS OP THE RESPIRATORY SOUND. 25
the beginning, that this succession of symptoms was observed;
which would encourage the idea that its absence, in the other cases,
was due to our not having ausculted sufficiently early, rather than
to its non-existence.
The duration of this rale was variable — short, three or four days
at the most, when manifesting itself before the bronchial respira-
tion — much longer when it succeeded it. In a child of three years,
under these circumstances, it persisted for two whole months.
Existing sometimes alone, it was more frequently accompanied
by a bronchial inspiration or expiration: in some cases it was
heard around the tubal sound, and, as this latter advanced, the
rale preceded it to attack the adjacent parts.
In cases where it disappeared, it was replaced by different altera-
tions of the respiratory sound presenting nothing constant.
This rale is of great value in the diagnosis. The fact that it so
often precedes the bronchial respiration, and is heard where the
other is soon to appear, establishes, it would seem, a very important
relation of cause to effect. The shortness of its duration, when
anterior to the tubal sound, is explained by the rapidity with which
the hepatisation supervenes: while its length, when succeeding to
this latter, confirms the remark already made, of the tardy resolu-
tion of pneumonia in younger children. We can then establish
the principle, that, when in a child of from two to five years, pre-
senting for some days some slight modifications of the respiratory
murmur, the sonorous or sibilant rales, for example, we begin to
detect a subcrepitons rale with equal and numerous bubbles, there is
strong reason to suspect the immediate invasion of a pneumonia.
Crepitous rale. — This rale, pathognomonic of the pneumonia of
adults, does it exist in children? Gerhard and Rufz say never in
children from two to five years : this appears to us erroneous, for
we have observed it in nine of our patients: and we are quite sure
never to have mistaken for it a subcrepitous rale, as we find it
clearly mentioned in our notes as a crepitous rale, excessively fine^
as in the adult. With the exception of three cases, it has always
been mingled with bronchial respiration : once it appeared on both
sides behind, and was replaced the next day by a subcrepitous
rale: another time it occupied the whole of the right back. In this
case, the child succumbing twelve hours after, we found the lower
lobe of a violet colour externally, of a deep red on incision, impene-
trable to the finger, still swimming upon the surface of water, and,
when pressed, giving issue to a great quantity of blood, with a little
air. This description corresponds entirely with the inflammatory
engorgement of Laennec, and, consequently, the lung, in this case,
was in progress towards hepatisation, the rapidity of the fatal ter-
mination alone preventing its arrival there.
In older children, the "crepitous rale is admitted by all patholo-
gists. We have met it eleven times, always intermingled with a
bronchial respiration. Its shortness of duration is quite remark-
26 HILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
able, one or two clays at most, never reappearing in the points
where it primitively showed itself.
The value of this rale is very great, as being a predecessor of
bronchial respiration ; nevertheless, as compared with the subcre-
pitous, its importance is diminished by its rarity.
In closing the history of these rales, we would call the reader's
attention to their duration being shorter, their march less regular, and
their transformations more numerous in the child than in the adult.
Our observation confirms, also, the remark of M. Guernard, with
regard to the facility with which we cause their disappearance, by
keeping our little patients a short time seated, and their greatest
distinctness at the moment when the child is raised from his bed.
Bronchial Respiration.
Of all the alterations of the respiratory murmur, this deserves the
most particular attention : it was present in two thirds of our cases,
and where it is not in our notes, the lesion was either very limited,
or auscultation had not been practised during the latter days of life.
A remarkable fact, often established by our cases, is, that frequently
this modification of the respiration was only heard in the expira-
tion, while the inspiration continued pure, or accompanied by some
rale. In these cases, the expiration, prolonged and bronchial, mani-
fested its peculiar note in the little accompanying cry. We have
observed this phenomenon more generally in the younger subjects,
and at two particular stages of the disease, viz. : either before or
after the appearance of the bronchial respiration, when the disease
was beginning to limit itself.
But why is it that the bronchial respiration was thus more fre-
quently heard in expiration?
In children from two to five years, lobular pneumonias, of one
kind or the other, being, without contradiction, the most frequent
form of the disease, it is natural to suppose that this stethoscopic
phenomenon or.gmates in this peculiarity. The little nodules, with
regard to their influence upon the respiratory sound, have the same
effect as tubercles. Now, since Jackson, 1 we all know a prolonged
expiration to be a sign of tubercles scattered in the pulmonarv pa-
renchyma. In children from two to five years, as we have already
said, the bronchial respiration was, in a certain number of cases,
preceded by rales of different natures. In the subjects more ad-
vanced, it was often ushered in by an obscurity of the respiratory
sound, and m this c ass, more frequently than in the other, it was
the first symptom established. '
In children from two to five years, it has always existed pos-
teriorly, and most commonly near the vertebral column
In those from five to fifteen, we have, in the great majority of
1 The late James Jackson, jr., of Boston.— P.
MODIFICATIONS OF THE RESPIRATORY SOUND. 27
our cases, found it behind : four times only anteriorly, of these
once at the level of the right middle lobe, once at the anterior and
middle part of the two lungs, and, finally, in the two other cases
under the clavicles. In the greater part of our patients, we have
found it for several successive days.
In children from two to five years, in cases terminating favour-
ably, the bronchial respiration disappearing, gave place to divers
modifications of the respiratory sound. In those cases, on the con-
trary, where death supervened, it persisted until that event, and
this persistence, when it coexisted with an increase of the general
symptoms, was considered by us of very grave import ; whereas
in a child of nine years, in whom the disease was developed in a
state of perfect health, the bronchial respiration was heard several
days after the disappearance of the febrile symptoms, and when, to
all external appearances, the disease no longer existed.
Although generally easy to hear, we ought to remark, that the
presence of rales, the difficulty of inducing our little patients to
cough, added to their repugnance to examination, sometimes mask
its character. But without regard to the difficulty of its perception,
can bronchial respiration in children possibly be confounded with
any other stethoscopic sign 1 We have no doubt of it. In a good
number of cases, we have seen persons little accustomed to aus-
cultation, especially of the healthy lung of children, mistake the
normal puerile respiralion for the bronchial; nevertheless, the dif-
ference is great, for however puerile it may be, it always gives the
sensation of air entering a number of vesicles ; besides, it is only
heard in the inspiration, whereas the bronchial character especially
manifests itself in the expiration.
There is, however, a variety of respiration still more difficult to
distinguish from the bronchial, viz. a rude respiration; and we
even incline to think that this rudeness is, in some cases, the index
of a pathological condition differing only in extent from that giving
rise to the tubal sound; we have observed it only a small number
of times. More than this it has offered nothing constant, either in
its duration or in the rales preceding or succeeding it.
A bronchophony has always accompanied the bronchial respira-
tion, whenever we have succeeded in eliciting a few words from
our little patients; in some cases, the resonance of their plaintive
cry has replaced with advantage the bronchophony which we could
not establish.
The respiration is sometimes quite obscure: this character pre-
cedes immediately the bronchial respiration, or else shows itself
at different epochs of the disease. The duration of this state was
generally very short.
To conclude ;— of all the signs which auscultation gives us,
the bronchial respiration is the most precious aid; it is the only
pathognomonic symptom of inflammation of the pulmonary paren-
chyma, indicating by its extent that of the disease, and by its per-
sistence the gravity of our prognosis.
28 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
Percussion.
As a diagnostic sign, percussion is of much less value than aus-
cultation ; it furnishes no results in the simple lobular form of the
disease ; it is only useful where the hepatisation is become general,
or from the commencement has taken the lobar form. We find
dulness on percussion signalised in many of our cases, always in
proportion, both in extent and degree, to the bronchial respiration,
generally developed at the same time with, never, however, before
it.
Percussion, to be useful, should be practised with much care,
and the observer should be perfectly acquainted with the natural
resonance of the child's chest. The thorax of the young subject
being naturally very sonorous, the flatness is seldom any thing
more than relative. The comparative sonorousness, also, of the
different parts of the chest is not to be overlooked ; thus, the infe-
rior dorsal region being naturally the most resonant, percussion
has never given but a relative degree of dulness.
There are even cases of greater difficulty, as where a dour,
hepatisation has gained the same level on the two sides, and
where in consequence we have no longer any point of comparison,
M. Hourmann, who allows but little value to percussion, insists
somewhat upon important results obtained from the application of
the palm of the hand upon the chest. He thinks that the vibration
of the walls of the chest, from the cries of the child, always com-
municates to the hand upon the diseased side a more decided
vibratory thrill.
CHAPTER IV.
THE CONNECTION BETWEEN THE AUSCULTATION AND PATHO-
LOGICAL ANATOMY.
After the separate study of the alterations of the respiratory mur-
mur, and the pathological anatomy in this disease, we come natu-
rally to the question of the correspondence between the two.
To establish a comparison of this nature, we shall follow the
same steps as in the description of the pathological anatomy, and
as in the series of pathological changes we have found a chain
commencing with the capillary bronchitis and ending with the
lobar pneumonia ; so, also, we are able to establish a gradation of
symptoms admitting of a perfect parallel. There is the same dif-
ference between the stethoscopic signs of the capillary bronchitis at
one end of the chain and those of the lobar pneumonia at the other,
as there is between the pathological states of the luno- in these
AUSCULTATION AND PATHOLOGICAL ANATOMY. 29
cases : and as the intermediate lesions are but the union of the two
extremes in different proportions, so their symptoms are a propor-
tionate combination of those furnished by the same extremes.
To illustrate our remark, a bronchitis reveals itself by a mucous
or subcrepitous rale ; a pneumonia, by a bronchial inspiration or
expiration ; and the predominance of either of these in a combina-
tion of the two, is the index of the like predominance of either of
the affections — inflammation of the mucous membrane or of the
parenchymatous structure of the lung.
For these reasons, and to facilitate our discussions, we give a
name to each of these extremes. Thus we shall speak of the
capillary bronchitis, the bronchial mucus, and the mucous and
subcrepitous rales as the bronchial element, whilst the inflamma-
tion of the parenchyma, with the bronchial respiration, will be the
parenchymatous element, the predominance of either making the
excess of its element in the particular affection of the lung.
This understood, it remains to us to complete the parallel, in
properly estimating and specifying the degree of combination of
the two. In this we shall support ourselves wholly by our observa-
tions, and although, with our point of departure, we might make a
diagnosis from theory alone, we shall avail ourselves of this latter
only to facilitate and illustrate our facts.
We shall first call the attention to the different varieties of pneu-
monia uncombined, examining afterwards their symptoms when
j united with, or complicating some other of the alterations which
I we have described.
Vesicular Bronchitis or Pneumonia.
This affection has always occurred to us in connection with some
other form of pneumonia, or at least a capillary bronchitis; but it
is easily conceivable that the bronchial element is here the only
existent one, both as symptom and pathological state.
Lobular Pneumonia.
It is impossible to study the characters of this inflammation in
> r its state of perfect simplicity, as it is never met with without a co-
il existent bronchitis, or at least an abundant secretion of mucus ;
' thus, instead of finding a pure hepatisation, we have a combination
; of our two elements.
ffl) But. what a variety of circumstances influence the predominance
a of one or the other? We have, for example, some scattered points
iil of pneumonia, with an abundant effusion of mucus; here is predo-
ii minance of the bronchial element. On the other hand, a case pre-
iffl sents a slight quantity of mucus, with but thickly disseminated
:l» points of pneumonia ; here the parenchymatous is the most declared :
e the same difference, if the little nodules be superficial or central,
I I voluminous or small in size.
30 RILLIET AND BARTHEZ ON PNEUMONIA OK CHILDREN.
Hence the great irregularity of the simple lobular pneumonia,
which has not yet become general.
It is always to be kept in mind, however, that the bronchial
element is much more universal than the other, and, as it were,
surrounding it, it is the more easily detected by the ear. Thus, in
all cases, where the autopsy has shown a lobular pneumonia of the
whole or part of the lung, we had during life observed in the cor-
responding mucous or subcrepitous rales, remarkable for their
persistence, having endured from the commencement of the disease
until death. In these cases the percussion has furnished us no
light, for the resonance was nearly always equal to that of the
opposite side.
In a small number of our observations we have met with super-
ficial points of pneumonia in those parts of the lung where auscul-
tation had delected a drier and finer rale, surrounded by the moist
rale of a bronchitis, and this we have regarded as the commencing
development of the parenchymatous element.
At other times we have heard a prolonged expiration or a very-
rude inspiration always accompanied by a rale more or less fine,
and always at points where the autopsy revealed an assemblage of
a somewhat large number of the little nodules of pneumonia: in
these cases, in fact, we consider the lobular pneumonia to play the
part of tubercles in producing the phenomena of the auscultation.
We have also heard the bronchial sound in the expiration, and
even both in expiration and inspiration, in cases where the mucous
rale became less abundant; and these symptoms have disappeared
upon the bronchi becoming again filled with fluid.
This occurred in points where the autopsy afterwards demon-
strated a lobular pneumonia.
Finally, we are to observe that all the symptoms of the paren-
chymatous inflammation are more easily appreciated at the summit
or middle, than at the base of the lung; it is there that we have
been most sure of our diagnosis, because there the subcrepitous
rale is less abundant, and at times even absent entirely. From
these remarks we may deduce.
1. Lobular pneumonia is more easy of detection superiorly than
inferiorly, but as if does not affect any particular part of the Irmg,
when we find it in one portion we may suppose it to exist else-
where, and the manifestation of the slightest symptom of the paren-
chymatous element authorises us to admit its more general exten-
sion, especially if the bronchial element be very welf declared, and
the natural symptoms lead us to suspect a pneumonia.
2. A single examination does not suffice for a positive diagnosis,
but it should be repeated often in the same day, to seize, if there
be any, the changes from the one element to the other.
3. Not being able to augment the parenchymatous element, we
should seek to diminish the bronchial. Thus, in all cases it is use-
ful to free the child's chest of any mucosities, and in this wc shall
have the additional advantage of assisting our diagnosis.
AUSCULTATION AND PATHOLOGICAL ANATOMY. 31
With these precautions, our stethoscopic diagnosis will be cer-
tain, if not in all, at least in the greater number of cases ; and if we
will avail ourselves of the other signs to be hereafter detailed, we
shall seldom be found at fault.
Simple Lobular Pneumonia becoming general.
In those cases the two elements, the bronchial and the parenchy-
matous, are equal, and manifested nearly at the same time, what-
ever may be the amount of either.
It is easily conceivable that the pneumonia must have become
ahead}' - general in a certain extent, for these two symptoms to be
constant.
Thus, a bronchial respiration or expiration, with a mucous or
subcrepitous rale and dull on percussion, are the peculiar symp-
toms of this affection ; we have, however, seen one case where the
bronchial respiration was not heard till the evening before death,
although the pneumonia had become general, and advanced even
to the third stage in some places. In this case, the mucous rale
was extremely full and abundant, and the bronchial tubes were
crowded with mucus. #
When we can follow the march of a lobular pneumonia in
progress towards the lobar form, we find first the rales, then an
expiration, or a bronchial respiration, unequally disseminated and
extending little by little till it involves a considerable space.
And to chow that this is not merely in the imagination we will
transcribe a portion of one of our observations.
1st day. — Right back, subcrepitous rale rather rare in both times
of the respiration ; at the left summit a little sonorous rale.
2d day. — Abundant subcrepitous rale on both backs.
3d day. — Behind, at the left base, and at the middle of the right
lung, bronchial expiration, mingled with a somewhat coarse sub-
crepitous rale, heard above and below the point of the bronchial
respiration.
4th day. — In the whole height of the right back, bronchial expi-
ration, with a little subcrepitous rale at the base; on the left the
bronchial respiration is scattered here and there.
5th day. — Respiration fully declared as bronchial in the two
upper thirds of both backs; below, fine subcrepitous rale.
At the autopsy there was found a pneumonia originally lobular,
but already become general.
It remains now to decide if auscultation can teach us the time
necessary for a lobular pneumonia to become general. Our ob-
servations offer us little assistance upon this subject ; nevertheless,
considering the rapidity with which the bronchial respiration de-
clared itself after the catarrhal period in the case just detailed, we
may conclude, that its march, once commenced, is very rapid. We
shall see hereafter, however, that the rapidity of this progress is
32 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
subordinate to the nature of the disease upon which the pneumonia
supervenes.
Lobar Pneumonia.
The crepitous or subcrepitous rales, bronchial respiration, bron-
chophony, and dulness upon percussion are the characters of this
pneumonia as well in the child as in the adult.
In the younger children, however, the bronchial element always
exists : thus in those cases, the rale is more moist than in older
subjects, where the parenchymatous element, on the contrary,
predominates in the auscultation as at the autopsy.
It is only in the lobar pneumonia that we have a difference thus
made by the age of the patient ; in the lobular form we have been
able to establish no such distinction.
Carnification.
This affection is generally of too little extent to give rise to any
well marked symptom. Most generally we have only noticed a
mucous or subcrepitoys rale, with a slight diminution of the reso-
nance upon percussion ; and a careful examination of all our ob-
servations leaves us with the general idea that in an equal extent
of lesion, carnification offers much less an amount of stethoscopic
signs than hepatisation. Twice, however, in a vast carnification,
we found, in ausculting at various intervals, the bronchial respi-
ration.
Thus far we have the history of the simple cases. But a com-
plication of the pneumonia with any other disease of the lung must
cause many modifications in their signs. These complications are
of two kinds : either several species of simple pneumonia are united
in the same point, or else there is joined to it some one of those
lesions, of which we have not yet detailed the symptoms.
The first division will detain us but a few moments; its signs
must depend upon the mixture, more or less considerable, of the
two elements ; we have seen cases of the union of both species of
bronchitis, the capillary and the vesicular, of this latter or perhaps
of both with a lobar pneumonia or carnification. In the first case
the bronchial element existed alone; in the second the parenchy-
matous predominated. We would be understood, however to allow
that auscultation does not furnish a differential diagnosis' between
these simple and the complicated affections.
The second class comprehends those cases where a dilatation of
the bronchi, or an emphysema occurs in conjunction with the
pneumonia.
A priori we should be unable to say what might be the influ-
ence of the dilatation of the bronchi upon the auscultation • for if
on the one hand it would produce bronchial respiration by the in-
creased size of the tubes, on the other it must facilitate the mucus
AUSCULTATION AND PATHOLOGICAL ANATOMY.
33
rale, rendered more abundant and more moist by the quantity of
tluid, and the greater space allowed to the formation of the bubbles.
Facts show us that both these circumstances may occur ; we
have observations of dilatation of the bronchi in which the bron-
chial element predominates, while in others it is the parenchy-
matous.
But in this latter case we would suggest the question whether
the mucus was or was not charged with air, for this appears to
coincide with a remarkable change in the production of the rales.
We judge so by two cases, in both of which the parenchymatous
element predominated in the auscultation, whilst at the autopsy
the bronchial appeared the more abundant : one was a case of vesi-
cular bronchitis, with a lobar pneumonia, and a very abundant
quantity of mucus ; the other a lobular pneumonia become general
in the first and second degree with a dilatation of the bronchi, and.
also a large secretion of mucus. In the first case, we had a bron-
chial respiration with very little subcrepitous rale in the same
points: in the second we had a pure crepitous rale: but in both
these observations, the mucus was not charged with air, or rather
we found a puriform liquid, which seemed never to have been
penetrated by the air, and therefore not to have contributed to the
stethoscopic sound of bursting bubbles. Thus in these cases the
sounds emanated from the parenchyma of the lung.
To conclude, we find only one case of vesicular emphysem
complicating the pneumonia ; this case, one of the most compli-
cated of all, was a capillary and vesicular bronchitis, with lobular
pneumonia at the third stage, dilatation of the smaller bronchi, and
emphysema, showing the bronchial element in excess as patholo-
gical alteration and consequently as symptom. Besides the fun-
damental symptoms, we are to regard also a third — the intensity of
the respiratory sound. In one case, this, in consequence of the
emphysema, was nearly nothing, while the resonance on percus-
sion was exaggerated. In addition, we had presented to us another
phenomenonwhich, according to Laennec, may be referred to the
emphysema as cause : thus, at any moment of the disappearance
of the mucous rale, we heard a succession of dry crackles, a sort of
gross crepitous rale. These crackles could not be attributed to the
lobular pneumonia, as they were too large and heard in an extent
too considerable.
In this case the emphysema was the phenomenon clearest cha-
racterised, and its symptoms were the following:
Mucous rale disappearing after cough, leaving the respiration
very obscure, with a return of the rale, alternating with the dry
crackling. Resonance on percussion much exaggerated.
In conclusion, the following may be regarded as the stethoscopic
signs of each of the alterations which we have described :
^Capillary and vesicular bronchitis :— mucous or subcrepitous
rales; natural resonance upon percussion; lobular pneumonia:
mucous or subcrepitous rales, mingled at times with a rale more
16— c ril 3
34 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
dry in its character; a roughness of the respiration ; prolonged or
bronchial expiration ; resonance natural.
This latter species become general : — mucous or subcrepitous
rale, with bronchial respiration scattered or rapidly spreading ; dul-
riess.
Lobar pneumonia; crepitous or subcrepitous rales, bronchial
respiration, bronchophony, dulness.
If a dilatation of the bronchi be joined to one or the other of
these affections, it is sometimes the mucous or subcrepitous rale,
sometimes the bronchial respiration which are exaggerated.
In all that precedes we have as yet said nothing of the stetho-
scopic signs marking the change of the pneumonia from the first
to the second or from the second to the third degree. We have
however spoken of one case where a well manifested pulmonary
engorgement gave for symptom a pure crepitous rale. As for the
distinction between the second and third degree, it would appear
impossible to establish it, and for this very simple reason, that
in all our cases of gray hepatisation, there existed no considerable
softening of the parenchyma. Now Laennec asserts that the infil-
tration of pus into the pulmonary parenchyma affords us no new
sign, as long as it remains in a concrete state. But even supposing
the pus to have softened, the mucous rale, which, according to this
author, indicates the change, would be of no use to us. considering
its excessive frequency in children.
CHAPTER V.
CAUSES.
After the study of the anatomical lesions in the pneumonia of
children, and the exposition of the physical symptoms which cor-
respond to them, we come naturally to the question of the circum-
stances favouring the development of the disease under considera-
tion.
A fact, which strikes at first view, and which has been noted by
ail authors, is, that in the large majority the pneumonia supervenes
in the course of some prior affection. This has been especially
insisted upon in children of from two to five years. Gerhard and
llufz go even so far as to say that idiopathic pneumonia does not
exist at that age. This assertion we cannot admit in all its rigour,
since we possess three examples of children of five years, in whom
the disease was developed in the midst of perfect health : but we
recognise the truth of the general proposition ; of forty patients be-
tween these ages, only three were in full health at the commenee-
ment of the pneumonia.
But more, it is not solely in these first years of life that the dis-
CAUSES. , 35
ease is rare in an idiopathic form : it is the same in the succeeding
periods. Our observations prove this very evidently. Of twenty
patients from six to fifteen years, six only were in good health at
the invasion of the malady, the others were attacked with different
diicases: measles, small-pox, typhoid fever, hooping-cough, gan-
grene of the mouth, &c.
From these remarks it results that children may be attacked with
two kinds of pneumonia; one somewhat rare which may be styled
the idiopathic, or the primitive, the other much more frequent,
which we shall call the complicated or secondary form.
This fact once admitted, what are the causes exerting an influ-
ence upon the development of this inflammation.
Age is one of the most efficient of the predisposing causes, since
from two to five years the malady is by far the most frequent. In
sixty patients, forty were from two to five years of age, and twenty
between five and fifteen : and the real proportion is even greater
than this, as the number of beds in the ward for the older children
is much the more numerous, and the admissions there consequently
more frequent.
To corroborate our assertion we will cite the result of the tables
of pathological anatomy drawn up by M. Haese, who in one hun-
dred and eight autopsies found a pneumonia seventy-one times in
children between two and five years, and thirty-seven times Only
between the ages of six and fifteen.
Age exerts an influence not merely upon the frequency of the
disease, but equally upon its particular form. We are of opinion,
however, that the proposition, that lobular pneumonia is peculiar
to the younger class of children, is too general — for although with-
out any doubt it is more frequent at these ages,' still we possess an
observation of a perfectly well marked lobular pneumonia in the
partial form, in a child of nine years. And. in an examination of
facts furnished by our predecessors, we find, that the first case of
M. Burnet, is this form of the disease succeeding to measles, in a
girl aged eight years ; and his fifth is of the same affection in a
child of nine and a half years : and lastly M. de la Berge's first ob-
servation is in the same category.
Another fact, tending to limit the influence of early age upon the
particular form of the disease, is, that from the observations of MM.
Valleix and Vernois, the lobular form is very rare in infants.
Sex has not appeared to us to exercise any well marked influ-
ence upon the development of the pneumonia in the first class of
our patients ; neither has it in the second series, when the disease
complicates some pre-existing affection : but according to Ger-
hard, idiopathic pneumonia from the ages of five to sixteen is more
common in males than females.
Authors vary upon the time of the year most favourable to the
production of pulmonary inflammations. M. de la Berge, reason-
1 See table of Pathological Anatomy.
36 RILLIET AND BARTJIEZ ON PNEUMONIA OF CHILDREN.
ing from the fact of the great number of eruptive fevers in spring
and autumn, advances an opinion that lobular pneumonia is more
frequent at these seasons. M. Leger makes the same observation ;
and Dr. Gerhard assures us that idiopathic pneumonia is the most
common in the months of April and May.
One of our colleagues, M. Becquerel, having had the kindness to
place at our disposition a list of the pneumonias occurring in the
service of acute diseases, (girls.) during the months of April, May,
and June, we are enabled, in uniting his notes with ours, col-
lected at the beginning and end of the year, to give a complete
table of all the pneumonias observed in this service during the year
1837. We would observe, however, that circu mstances beyond our
control having prevented the observation of a few cases, which
occurred in the latter end of March, this month will not enter into
our table of results. The total of pneumonias in the eleven months
is ninety-four, divided as follows:
(We have marked not only the number of the pneumonias, but
also the relative frequency of the idiopathic and complicated.)
Months.
Number.
Idiopathic.
Complicated,
January,
February,
March,
8
18
1
5
7
13
April,
May,
June,
8
5
7
1
1
1
7
4
6
July,
August,
September,
October,
13
5
5
9
1
I
13
5
4
8
November,
11
2
9
December,
5
5
Total, 94 13 81
Different consequences may be deduced from the foregoing
tables. 1. What we already knew ;— the enormous disproportion
between the frequency of the idiopathic and complicated pneu-
monia; 2. the rarity of idiopathic pneumonia in the warmer
months of the year. We may moreover observe, that the number
of complicated pneumonias depends upon the prevalence, at the
time, of those diseases, upon which they are liable to supervene.
Thus if the month of February presents the largest number, we
find the cause in the epidemic prevalence of the grippe at that sea-
son of this particular year, (1837.)
Taking into account the force of the constitution, we have made
the remark that nearly all our younger class of patients presented
a very delicate complexion, while those from six to fifteen years
appeared generally to enjoy a very good constitution.
CAUSES.
37
Different debilitating causes appear to exert a very manifest in-
fluence upon the pneumonia of children, we refer particularly to
the diseases in the course of which the affection of the lungs su-
pervenes, a prolonged residence at the hospital and the continued
decubitus upon the back.
It will not be uninteresting, to examine what are the affections
with which the pneumonia is most frequently complicated, as well
as the comparative frequency of these diseases in the different ages
— a glance at the following table will satisfy us upon these points :
From tioo to five years.
Diseases.
Measles, .....
Hooping-cough,
Slight catarrh,
Small-pox,
Varioloid, or scarlet fever,
Chronic enteritis,
Gangrene of the mouth,
Rickets, ....
Hardening of the cellular tissue,
Paralysis of the arm, .
N
jmber of
. 11
3
. 2
2
. 1
6
I
1
1
1
cases
From six to fifteen years.
Diseases.
Measles,
Small-pox,
Hooping-cough,
Bronchitis and enteritis,
Typhoid fever,
Gangrene of the mouth,
Number of cases.
. 4
3
. 1
1
. 2
2 1
From this table it results, that from two to five years of age
measles is the disease most frequently complicated by pneumonia,
then chronic enteritis and hooping-cough ; whilst after five years
it is measles, with small-pox second in frequency. Although in
our result gangrene of the mouth only appears three times, we
can assure the reader, that, of all the diseases of children, it is the
most frequently complicated by pneumonia; for we have seen this
inflammation in eleven cases of gangrene of the mouth ; and M.
Baudelocque's experience is perfectly in accordance with our own.
Independently of the diseases just mentioned, predisposing more
or less decidedly to pneumonia, we would observe that the cuta-
1 The tuberculous affection, as predisposing cause, does not appear in
these tables, as we have eliminated all the cases of pneumonia supervening
in advanced phthisis.
38 RILLIET AND BARTHEZ OX PNEUMONIA OF CHILDREN.
neons system presented different affections (ecchymosis, eczemas,
&c.) in one half of our cases.
The prolonged sojourn at the hospital, and especially the decubi-
tus upon the back, have been very justly considered by M. Leger. as
prejudicial to young children ; an assertion confirmed by our own
cases, for we possess observations in which the sole cause, which
could be considered as productive of the disease, was the long de-
cubitus upon the back.
The explanation of this is easy. The weakness and the diffi-
culty of the expectoration in children, favours, in certain cases, the
stasis of the liquids in the most inferior portions of the lung, where
their sojourn determines an inflammation of the neighbouring
parts, — we say determines the inflammation, because, in the great
number of cases the anatomical changes have not appeared to us
as analogous to those of the hypostatic pneumonia, and we would
not give a purely mechanical explanation either of the lobular or
lobar hepatisation. We advance here an opinion directly opposed
to that of Dr. Gerhard, who thinks that pneumonia in children
from two to five years of age possesses a very great analogy with
those sanguineous congestions resulting from a mechanical obstacle
to the free circulation of the blood in the lungs. It seems to us, that
to refuse to the pneumonia of young children any purely inflamma-
tory character, is to put ourselves in direct opposition to facts. A
rapid progress, formidable symptoms of reaction, evident traces of
an inflammation in the lung or its dependances — are not these suf-
ficient to characterise an inflammatory affection ?
Authors have not contented themselves with the simple causes
above enumerated, but have wished to ascend higher, and seek in
the peculiar structure of the child's lung, the rapidity of the circu-
lation, the number of inspiratory movements, &c, an explanation
of the frequency of pneumonia at this age. So far these pretended
causes are to be considered merely as flights of fancy, more or less
ingenious, not as settled and positive facts.
Latterly MM. Burnet and De la Berge have sought to connect
pneumonia with a cause more general than any we have men-
tioned. They have advanced that the lobular pneumonia always
succeeds to an inflammation of the bronchial tubes. This is a
question of sufficient importance to receive a special and attentive
examination.
If our details, when upon the subject of the pathological anato-
my, be recalled, it will be seen that in many cases the most atten-
tive examination of the smaller bronchi did not enable us to assure
ourselves of the existence of an inflammatory lesion of these tubes.
Pathological anatomy thus affording no light, we are obliged
to have recourse, for a solution, to a careful examination of ^he
symptoms. And what do these teach us? That in the great ma-
jority of cases, not only in the variety described by M. dela Berge,
but also in the diffused lobular species, and even in the lobar form
in the youngest children, there exist cough and different altera-
RATIONAL SYMPTOMS.
39
tions of the respiratory murmur, supposed to be dependent upon a
bronchitis, before the positive signs of a parenchymatous inflamma-
tion have declared themselves.
Therefore, without denying the possibility of a pneumonia origi-
nally commencing in the parenchyma, in children from two to five
years (for we possess examples of it) we regard the occurrence as
exceedingly rare. But very frequently it is impossible to recognise
any connection between the gravity or extent of the catarrh which
precedes, and the pneumonia which follows; so that the bronchitis
ought to be regarded as predisposing to inflammation of the paren-
chyma, rather than as an occasional active cause ; and the pheno-
mena to be those of a propagation of inflammation in continuous
textures.
Thus, to sum up ; — nearly all the causes of pneumonia in children
are reduced to the predisposing; and if a change of temperature, a
suppression of an habitual discharge, a repercussion of a cutaneous
disease, or the exanthemas, are capable of its production, our ob-
servations enlighten us very little with regard to the degree of their
influence. We have, however, thought ourselves to have observed
that sudden changes of temperature had a manifest influence upon
the development of this disease. Thus, in two cases, we have
imagined that a sudden chill appeared to have been the occasional
cause of the appearance of the pneumonia. In one of these a
young girl, ill with measles, was seized with all the symptoms of a
pneumonia (cough, pleuritic pain, &c.) after putting her feet upon
the ground, the eruption being in full vigour; in another, a young
boy, going out the eighth day of the eruption of small-pox, was
taken'' four days after with cough, dyspnosa, and we discovered from
the day of entrance all the signs of a pneumonia at the second
degree. We have observed, in young children labouring under
diseases of the skin or hairy scalp, the falling off of the scabs or
the suppression of the discharge, far from being the cause, to be
rather the result of the inflammation, and the affection of the skin
to be sensibly modified after the full development of the pneu-
monia.
CHAPTER VI.
RATIONAL SYMPTOMS.
The pneumonia, once declared, determines in the organism an
assemblage of symptoms which we must attempt to comprehend.
It has been lately often repeated, 1 that children manifest in their
1 The authors refer here to the ideas of M. Jadelot, one of the physicians
at the Enfans Malades, upon the lines of the countenance as diagnostic of
visceral disease. — P.
40 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
countenances, the signs of the diseases with which they are attacked;
it has been admitted that certain modifications of the lines of the
countenance correspond constantly with certain thoracic or abdo-
minal affections: we have attempted, in the larger part of our
cases, to appreciate the value of these diagnostic signs, and the fol-
lowing are our results : —
We have remarked nothing constant in the different folds of the
skin of the countenance ; they appeared to us rather as the index
of a general suffering than as pathognomonic of disease of the
viscera, either of the chest or abdomen. We will not say the
same, however, of the dilatation of the alas nasi, which we have
observed in nearly all our cases, immediately preceding the inspira-
tion, and lasting nearly the whole period of the disease. Sometimes
it was excessive, and nearly always proportionate to the acuteness
and gravity of the pneumonia. In young children the general
expression of the countenance was very various — sometimes pale,
sometimes coloured, at times only on a single cheek, but without
any reference to the side affected by the pneumonia; it offered in
several cases, from the commencement of the disease, a profound
and characteristic alteration, followed by a rapid emaciation. But
it would be wrong to consider this facial alteration as peculiar to
the younger series, for we find it noted in several of our observa-
tions of children from six to fifteen years, in whom the termination
of the disease proved fatal.
Paleness and puffiness of face are notes in many of our observa-
tions, coinciding often with infiltration of the extremities.
In young children, being unable to establish the existence of a
chill, we cannot say if the disease commences in this manner ; but
we are certain that, after the invasion of the pneumonia, the heat
of the skin was sensibly exalted in the larger part of our patients:
most usually it was great, sometimes excessive, but almost never
accompanied with moisture.
In older children the disease commences with a very apprecia-
ble chill, to which the heat of the skin soon succeeds.
The pulse was always counted— rarely under 120* in the
younger children it varied between this number and 140 to 150,
and has been observed as high as ISO. In children from six to
fifteen years it was less accelerated, as it more rarely attained 140
to loU, but the day of invasion it was always 120
In the greater number of cases after the commencement it pre-
sented no special character: usually full and regular, but nearly
always in the younger children, a few days before death, it became
ot an extreme smallness, sometimes nearly imperceptible. In the
cases terminating favourably, this smallness of the pulse was never
observed at any period of the disease.
The number of inspirations varied between thirty and eighty, in
DetwepiZ T tW ° S° fiVe ^ rS; in th0se from six ^fifteen,
n en H ? ^ r and T y - e] °- h{ - lD the half of lhe cas es the;
presented nothing particular; in the other half, at all ages but
RATIONAL SYMPTOMS.
41
specially in the younger series, we observed the following pecu-
liarities:— Sometimes they were anxious, very full, raising the
whole chest, or else they were entirely abdominal ; at other times
they were irregular, unequal, and interrupted; in some cases the
inspiration was normal, the expiration alone being hard, noisy,
painful, difficult at the commencement, and seeming to exact an
effort, and to be rather an active than a passive phenomenon.
A great number of our cases of pneumonia declaring themselves
at the hospital, we have been able to establish the increase in the
number of inspirations and pulsations at the moment of the decla-
ration of the disease ; we cannot too much insist upon the simulta-
neous appearance of these two symptoms. But we would be care-
ful to say that it is only on the first, second, or third day that we
are able to remark this, since later in the disease, under the influ-
ence of treatment, or causes which escape our observation, the
comparative march of the pulse and respiration becomes often irre-
gular, and even inverse: that is to say, we find an increase in the
number of pulsations to correspond to a diminution of the number
of inspirations, and vice versa.
After this separate examination of the pulse and respiration, let
us see the influence of the extent of the hepatisation upon these two
symptoms. When there was no complication of other acute dis-
ease, the acceleration of the pulse and respiration has been in direct
proportion to the acuteness and extent of the inflammation, with
the exception of some cases already alluded to, where the discre-
pancy was to be attributed in part to the treatment.
In the cases of pneumonia co-existing with an acute disease, the
measles, for example, the acceleration of the pulse and respiration
was sometimes extreme, although the inflammation of the lung
was very limited.
We think, therefore, that we may sny, in general the intensity of
the febrile reaction depended upon the extent of the inflammation.
This result, although a rigorous deduction from facts, so simple as
to appear to be established a priori, is nevertheless opposed to what
has been written by authors upon the lobular pneumonia; who
state the pulse and respiration to be always much accelerated.
An examination, however, of these observations of MM. Burnet
and de la Berge, shows us, that in all the instances of acceleration
of the pulse and respiration, the fever explains itself very naturally
by the existence of certain coexisting affections, measles, typhoid
fever <fcc. Independently of the extent of the hepatisation, the
reaction depends on the nature of the disease upon which the pneu-
monia supervenes ; we shall have occasion to revert hereafter to
this latter consideration.
When an effusion into the cavity of the pleura complicated the
pneumonia, we find mentioned in our notes a collection of symp-
toms which in a similar case might serve for diagnosis. We refer to
the paroxysms of suffocation. The oppression becomes extreme the
inspirations succeed each other with a prodigious rapidity, the face
42 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
is purpled, and these symptoms all disappear, to he in a short time
reproduced. In ordinary pneumonia the difficulty of the respira-
tion is sometimes very great; but in general its progress is more
or less regular, whether in the increase or decline, and does not
show itself thus under a paroxysmal form.
In cases where the respiration has been irregular or unequal, we
have not observed these circumstances to be dependent upon any
greater or less intensity of the inflammation ; in two cases, one of a
pneumonia of the whole posterior part of the lung, comprising also
the whole superior lobe, and the other only of the summit, the
respiration was in both remarkably unequal. And finally, in those
where it is noted as anxious, raising the whole chest, the pneumo-
nia was very extended, occupying even nearly the two entire
lungs.
The cough has been wanting twice: another time it was exces-
sively rare, (lobular pneumonia.) In regard to the great number
of cases in which it existed, it ought to be ranked among the im-
portant symptoms : but its value as such is much affected, inso-
much as it often occurred before the other signs of pneumonia
could be found to exist. In more than one half of the cases it is
noted as rare; but in those where it was observed as frequent, it
increased quite sensibly in proportion to the progress, and in direct
ratio with the extent of the inflammation. It diminished, however,
with the strength of the patients, and in the last days of life it was
entirely wanting. Nearly always it was dry, and in eight cases it
existed in paroxysms ; but in five of these there was a complication
of hooping-cough and very intense catarrh, and in another a pleu-
ritic effusion. Once it was remarkably hoarse, in a child at-
tacked with measles, at whose autopsy we found an erosion of
the vocal chords.
An important fact to be noticed in the history of this symptom,
is the period of its appearance. In children from two to four years
of age, whatever were the circumstances under which the pneu-
monia was developed, and whenever it has appeared under our
observation, the cough has always manifested itself at least a week
before the decided commencement of the inflammation. In older
subjects, in cases of an idiopathic inflammation, the cough, the acce-
leration of the pulse, and respiration, marked the opening of the dis-
ease, while in the contrary case, when the affection complicated a
catarrh, the cough was heard before the signs of the pneumonia
were at all marked.
The expectoration in our patients, from two to five years of age,
was wanting, in the greater number of cases, and has been noted
only (our times; in one it was sero-spumous, in two others sero-
mucous, and in the remaining one sero-mucous, tino- e d with ver-
milion-coloured blood. In those from six to fifteen years, it was
nearly always present ; in seven cases the sputa were coloured, and
ive times tinged with blood : in two cases of idiopathic pneumonia,
they possessed the rusty tinge peculiar to the disease in the adult.
RATIONAL SYMPTOMS.
43
We arrive, thus, at the same result as Dr. Gerhard, who, in twenty-
patients, only met this kind of sputa three times.
In the young children it was very difficult to assure ourselves of
the existence of pains in any part of the chest, both from their want
of the power of expression, and the difficulty of the appreciation of
their existence by percussion. We have, however, assured our-
selves of the presence of this symptom in three cases, in two aged
four years, and another five: one of the two former had been
attacked at the hospital with the disease, while in tolerably good
health : in the remaining two, the inflammation supervened in the
course of, or soon after, the measles. In the two former the pain
was seated below the nipple, in the latter it was sternal, and, con-
sequently, not corresponding with the pneumonia, which was situ-
ated antero-posteriorly on the right, and postero'-inferiorly on the
left side. In patients from six to fifteen it was more often noted,
as we have encountered it twelve times.
The epoch of the disease, at which the pain appears, is variable:
sometimes it is the commencement, and, after a duration of some
time, we have found, at the autopsy, old adhesions : at other times,
the pain appeared at the end of the disease, or during the last days
of life.
This thoracic pain was not as characteristic, nor of as long con-
tinuance, as in the adult: although really pleuritic, it has never,
in our cases, lasted but from one to three days.
The thorax in the greater part of our patients was well formed :
we have, however, observed in four cases that the chest was con-
tracted in front, and compressed on the sides, in a very sensible de-
gree : these children were aged twenty months, and two and three
years. In two other subjects the chest was remarkably arched in
front. Rickets, so frequent in children, is the special cause to
which we are to attribute all these alterations of symmetry; but it
would be difficult to determine exactly the precise influence ot
these deformities upon the production of pneumonia.
In children from two to five years of age, the decubitus was
either on the back, or indifferent; but we must mention that the
two patients, attacked with the pleuritic pain, changed immediately
after its invasion their mode of lying; thus— before, they lay indif-
ferently on one side or the other, but afterwards one preferred the
side of the pain, the other the opposite. In the children between
five and fifteen years, the decubitus has offered nothing specially
worthy of note.
The respiration and the circulation were not the only functions
offerino- remarkable disorders. The nervous system, so liable to
impressions in the child, presented various lesions in two thirds of
our cases— in all the young patients from two to five years, and in
half of those from five to fifteen.
In the former, the symptoms consisted most generally in an
anxiety and an agitation, sometimes carried to extremes They
showed themselves ordinarily at the commencement, and rarely
44 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
continued throughout the whole of the disease. In the greater part
of our patients this excessive anxiety was very well explained by
the extent of the disease, occupying the greater part of the lungs;
but in a child of two years, presenting only a few nodules of pneu-
monia, it must be referred to the eruptive fever which coexisted
with it.
Other patients, far from presenting this agitation, offered a re-
markable prostration and somnolence : in two of these cases the
disease attacked in tolerably good health, and the hepatisation
occupied all the lobe of one lung.
The children from six to fifteen years, especially the youngest,
presented sometimes an extreme anxiety, attended even with deli-
rium : in other cases of the disease, complicating other affections,
we observed a remarkable depression of the strength, frequent gid-
diness, &c. In a young girl, aged fifteen, attacked with the pneu-
monia during convalescence from typhoid fever, we observed the
return of the typhoid cerebral symptoms at the same time with the
development of the new inflammation.
In a single case only have we been able to observe those symp-
toms on the part of the nervous system, considered by some patho-
logists as simulating a cerebral affection. These pseudo-meningites.
appearing in the course of a pneumonia, are not so common as they
have been hitherto pretended : and if we glance at some of the
observations reported as examples of this particular form, we find
many of them to be well-marked cases of typhoid fever ; for ex-
ample, M. Leger's case, (pneumonia of the right side, with enteritis
and ataxic symptoms.) Nevertheless, there do exist in the Gazette
Medicale two or three examples of this particular form. Finally,
in one of our younger patients, (a child of five years,) a pneumonia
supervening in perfect health, assumed the typhoid character.
Headach was inappreciable in the greater number of our pa-
tients. Nevertheless, we have observed it once in the midst, and
once at the commencement of the disease, both times in patients
aged four to five years : five only of our older patients have made
any complaint, nearly always at the commencement, and, at times,
during the course of the disease. Of these five, four had idiopathic
pneumonias, and the fifth a pneumonia accompanying measles.
When the headach did exist, it was frontal, and was of no great
intensity.
In more than three quarters of the cases the digestive tube was
in a more or less abnormal state. Most were attacked with diar-
rhoea, slight in some cases, but more abundant in others, and con-
stituting one of the affections during which the pneumonia fre-
quently developed itself, (chronic enteritis.) The abdomen was
without pain, tympanitic, or the contrary: the tongue, nearly
always moist, was often covered with a white or yellowish 'coat.
In two children, one aged three and the other four years there
was slight spontaneous vomiting, but. only in the first day 'of the
disease. We have seen the appetite persist in some children
SKETCH OF THE DISEASE, ITS PROGRESS, &C. 45
attacked with a pneumonia, which progressed very slowly, (it was
of the simple lobular form in two of these.) In cases, on the con-
trary, where the inflammation was extensive, and assuming a very
acute type, the anorexia was complete, and in these also the thirst
was extreme, far exceeding any thing of the kind in the adult :
thus, we have seen young children swallowing with avidity every
liquid that was presented to them, and only desisting from the
necessity of respiration.
In the older subjects the digestive tube has offered no remarkable
symptom; thirst and anorexia have been noted in all the cases, and
sometimes there existed vomiting.
After thus enumerating one by one all the symptoms presented
by the pulmonary inflammation of children, we ought to examine
them grouped together, forming a single morbid entity. We should
seek to sketch a picture of the disease, showing its diagnosis, and
the march of its different varieties. This will form the subject of
the following chapter.
CHAPTER VII.
SKETCH OF THE DISEASE, ITS PROGRESS, &C.
Before commencing this description, what shall be the elements
of our divisions? Shall it be the pathological anatomy? Shall
we describe, as have done all our predecessors, the lobular and
lobar pneumonias as two distinct diseases? Or, imitating the ex-
ample of Gerhard, shall we form two great varieties, dependent
on the ages of the patients attacked by the disease? Or, further,
shall we divide our patients into two categories, according as the
disease attacks in full health, or supervenes upon some other affec-
tion, which it complicates?
The details into which we have already entered have shown us,
that the two forms of pneumonia are confounded by very appreci-
able gradations, and that the symptoms of a lobular pneumonia, be-
come general through the lung, do not essentially differ from those
of the lobar form : consequently, with the pathological anatomy for
our sole guide, we should find ourselves obliged to divide very
much our descriptions, for the same patient often presents on one
side a simple lobular pneumonia, while in the other there exists the
same form rapidly becoming general : now, how distinguish in the
same patient the symptoms and the progress of these two diseases ?
No more should age be the sole base of our divisions, since the
study of symptoms demonstrates to us that the form assumed by
the disease, and the progress that it follows, depend more upon the
conditions in which it manifests itself, than upon the time of life
46 R1LLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
at which it overtakes the patient. Finally, the mere consideration
of the anterior state of the health will no* better assist us to class
under one head all the varieties of the pneumonia of children.
Adopting, then, no one of these divisions exclusively, we will
lay them all under contribution— and desirous of presenting a
complete picture of the disease, of producing the physiognomy and
the particular expression of its different varieties; in fine, of giving,
in a word, a description which shall enable all, now unacquainted
with the pneumonia of children, to arrive easily at its diagnosis,
we have thought best to establish the following species — two prin-
ciples have served us for basis. The first, that the form of the dis-
ease is dependent upon its exciting cause. The second, that the
progress it follows partakes of the nature of the affection, in the
course of which it is developed : thus, the simple lobular pneumo-
nias become general, and the lobar pneumonias supervening upon
a long-continued affection, are clothed with the particular attri-
butes of chronic disease — while those, on the contrary, which arise
in perfect health, or in the course of an acute disease, take to them-
selves the acute characteristics. Hence two divisions.
1. Simple lobular pneumonia, the lobular becoming slowly ge-
neral, or the lobar form supervening in the course of a chronic
affection.
2. The simple lobular, the lobular rapidly extending itself, or
the lobar form attacking the patient in perfect health, or in the
course of an acute disease.
The first species is peculiar to the younger children, supervening
generally upon the chronic ententes so common at that aofe, some-
times after the exanthematous fevers, but in these latter long after
the disappearance of the eruption.
As it thus appears in patients, emaciated and enfeebled by long
standing disease, ils external symptoms are not well defined. The
cough is rare, sometimes even not present : the pain of the chest
does not exist, the expectoration is wanting, the skin pale and cold,
with oedema of the face and extremities : usually, however, at the
moment when the disease tends to become generalised, there ap-
pears a movement of reaction, manifested by an acceleration of the
pulse and respiration, and an increased heat of the skin.
The disease would, however, often continue completely latent,
if auscultation, coming to our aid, did not reveal the symptoms of
which a former full detail renders the enumeration unnecessary.
Despite the diarrhoea often colliquative, the appetite frequently
remains in full force, and the thirst is not augmented : the skin is
covered with ecchymoses and furuncles. Ulcerations arise either
on the nates or on blistered surfaces— the emaciation makes rapid
progress and the patient succumbs in the last decree of maras-
mus. &
Of all its forms, it is when in the simple lobular state that the
pneumonia is most difficult of recognition, but then also its diag-
nosis is least important: supervening under the most unfavourable
SKETCH OF THE DISEASE, ITS PROGRESS, &C. 47
conditions, and at an epoch when disease has already undermined
the powers of life, it adds but little to the gravity of the prognosis.
Surely it well merits the name of asthenic, given by M. de la B^rge :
but this appellation applies throughout its whole extent, without
any particular reference to his supposed second period, which we
confess has always escaped us. But even if we would establish
two periods for the disease, the first should be the asthenic and the
latter the sthenic, since, (as we have already explained) the reac-
tion takes place in these cases only at the moment of the generali-
sation of the pneumonia, and this generalisation is the last period
of the disease, the one immediately preceding the fatal termination.
2. The simple lobular, the lobular generalised, appearing in an
acute disease, with the lobar species under the same circumstances
or in perfect health, assuming an acute form, constitute our second
division. They all follow the same course in children from two
to five years: in those from five to fifteen they present some slight
differences between themselves.
The pneumonia of the former age presents two well marked
distinct periods, the one, which may be called catarrhal, the other
inflammatory.
The catarrhal stage presents nothing constant as to its length of
duration, but is always appreciable by its cough, generally not
intense, slight alterations of the respiratory murmur, the sonorous
or sibilant rales, the mucous cracklings, &c, without any accelera-
tion of the pulse or respiration : the appetite is preserved, and the
child still continues its sports, until finally there appears suddenly
and simultaneously an acceleration both of the pulse and respira-
tion, (marking the second period :) the skin becomes burning, the
alee nasi are widely dilated, and there is an anxious expression of
the face: the agitation, sometimes extreme, is replaced in other
cases by a remarkable somnolence and prostration : the ausculta-
tor in the first hours of the disease, recognises an obscurity of the
respiratory murmur, or a subcrepitous rale, without appreciable
dulness upon percussion ; later there appears a bronchial expira-
tion, accompanied by the same rale, the bronchial character finally
extending itself to both times of the respiration together with a no-
table dulness upon percussion: the general symptoms preserve all
their intensity as long as the pulmonary inflammation makes any
progress. .
At last the moment arrives when the pulsations and respirations
become irregular, the pulse extremely weak, the face purple, the
extremities cold : the prostration gives place to an anxiety in the
whole performance of the functions, the cough ceases ; the young
patients are attacked with prolonged gapings, uttering deep sighs,
the pulse finally becomes insensible and death closes the scene.
The progress of the hepatisation is sometimes so rapid as to pro-
duce death in two or three days.
In cases where the disease is to terminate favourably, the stib-
crepitou- rale begins to reappear, the broi chial sound is limited to
48 RILLIET AND BARTIIEZ ON PNEUMONIA OF CHILDREN.
the summit of the lunar or the root of the bronchi, and the respira-
tory murmur is again heard : while the local state is thus amelio-
rating, the general symptoms lose their intensity ; thus, the pulsa-
tions"and respirations are quickly diminished in number, the heat
of the skin gives place to a pleasant moisture, with disappearance
of the anxiety, &c. This resolution usually commences the seventh
or eighth day, but even as late as the twentieth the last traces of
the rale have not in some cases disappeared.
These remarks apply specially to children from two to five years.
In those from five to fifteen the differences in the progress of the
pneumonia are somewhat important : it may attack in two circum-
stances, — in the course of another disease, or in the midst of perfect
health. In the former case if the malady which it complicates he
catarrhal, we find the two periods much the same as in the younger
class of children.
If the pre-existing disease be not catarrhal, (typhoid fever, small
pox,) the pneumonia is remarkable for its insidious approach, a
cough is hardly present, the pain in the chest and the expectoration
are entirely wanting ; and as the pulmonary affection is developed
in the course of a febrile disease, we can with difficulty assure our-
selves of the acceleration of the pulse or respiration. But there is
one important symptom which may serve to arouse suspicion of the
commencement of the disease — the deep change of the expression of
the face, which we find noted in all our observations.
The idiopathic form does not differ in a sensible manner from
the same disease in the adult. It commences by fever, thirst, an-
orexia, pain in the head, cough, pain in the chest, and sometimes
vomiting : auscultation discovers a crepitous rale, bronchial respi-
ration and bronchophony ; the expectoration is often bloody but
rarely rusty ; the acceleration of the pulse and respiration is con-
siderable. The nervous symptoms are sometimes rather pro-
nounced, and we observe intense headach with anxiety or even
delirium. According to Gerhard and Rufz the mean duration of
this form is fourteen days. In the few cases we have seen, it has
been much longer; one of our patients quitted the hospital the
twenty-first day of his disease with the bronchial respiration still
present; and in another the subcrepitous rale, which had succeeded
it, endured six weeks.
CHAPTER VIII.
DIAGNOSIS.
After this exposition of the symptoms to assist us in the recogni-
tion of the pneumonia of children, let us see if there be no danger
of confounding it with any other disease of the respiratory organs.
DIAGNOSIS.
49
For example, what are the differences between pneumonia and
pleurisy, bronchitis and phthisis. "Simple pleurisy is a very rare
disease in children from two to five years ; for our part, we have
never met it, for whenever we have found a liquid in the pleural
cavity, there has always existed an hepatisation of the Lung, thus
usually confounding the symptoms of the pneumonia with those of
the pleurisy. In one case the absence of all respiratory sound,
where a bronchial respiration had been heard, immediately after
the declaration of a pleuritic pain, enabled us to recognise an effu-
sion complicating the hepatisation. We may also remark, that the
access of suffocation, mentioned in two of our observations, ap-
peared of some value as diagnostic of an effusion into the pleura,
cavity. But we must not assign too much importance to this
symptom, as we are not certain that a rapid hepatisation may not
give rise to the same phenomenon. Among the observations of
MM. Constant and de la Berge, we find two of a pleuritic effusion
diagnosticated by percussion and change of position.
In the older children, simple pleurisy is still a rare affection, dif-
fering however in nothing from the same disease in the adult.
A bronchitis severe enough to produce constitutional symptoms
is certainly very rare in children from two to five years. In the
immense majority of cases, when it puts on this form, it is compli-
cated with lobular pneumonia, and we have, in speaking of the
diagnosis of this latter, alluded to the great difficulty of distinguish-
ing these two affections, especially where the bronchial element is
predominant. A catarrh in the younger children not determining
any symptoms of reaction is characterised by cough, sonorous and
sibilant rales, mucous cracklings or even the subcrepitous rale, but
this latter is in general of short duration and its bubbles are very
unequal. As we have often heard a subcrepitous rale in cases
where we have afterwards found pneumonia, we would guard
against being understood to assert a subcrepitous rale heard on both
sfdes of the back to be a pathognomonic sign of bronchitis, such
an assertion would be in flagrant contradiction to facts, which we
have detailed above.
In children from rive to fifteen years, a pulmonary catarrh fre-
quently complicates other affections, measles, hooping-cough,
typhoid fever, &c, but it is also observed idiopathically, and then
it presents no difference in its symptoms with that of the adult.
The tuberculous affection of the lung ; can this simulate a pneu-
monia? In speaking of vesicular pneumonia we had occasion to
remark that a superficial examination might mistake the granula-
tions of inflammation for those of tubercles, and we have thus
pointed out their characteristic differences. Inattentive observers
also might regard the small abscesses of the lung as tubercular
excavatTons, but in those latter when existing in the parenchyma,
the surrounding tissue and the age at which they occur prevent all
mistakes of this nature. In fact we all know that in children, of
16-d ril 4
50 RILLIET AND BARTH1Z ON PNEUMONIA OF CHILDREN.
two or tiiree years, the tuberculous affection is rare, and that in the
cases where it is found to occur, the tubercles have never advanced
beyond the crude state. In older subjects, phthisis becomes ex-
tremely frequent, but its chronic character most generally diagnos-
ticates it from pneumonia. The diagnosis however is often very
obscure, especially when we are deprived of an accurate informa-
tion of the origin and progress of the disease. — To choose some
examples illustrative of this subject. A child has the skin hot, an
intense fever, dulness on percussion, and bronchial respiration un-
der one of the clavicles. Is it attacked with pneumonia ? We have
frequently seen this question decided in the affirmative and a treat-
ment, consequent upon such a view, applied to the case ; but ne-
vertheless the autopsy has proved these symptoms, in the great
majority of the cases, to be dependent upon a tuberculous infiltra-
tion of the lung. Besides such a diagnosis might be given a priori.
as a glance at our table of the seat of the lesions shows only two
cases of pneumonia limited to the anterior portion of the lung, and
only one of hepatisation immediately beneath the clavicle. The
signs of an idiopathic pneumonia under the clavicle, although rare,
do sometimes exist, when this affection is developed in a tubercu-
lous subject. And as the young patients are often brought to the
hospital for the complication alone, with the very incomplete in-
formation we can obtain of the former health, we might easily
overlook the original disease, and give a prognosis founded on too
favourable a view of the case. In these difficult cases great regard
is to be paid to the intensity of the febrile movement, and the pro-
gress of the disease. Thus, a persistence of the physical, after the
decline of the rational, symptoms is very probably due to a tuber-
culous affection. But finally, when the tubercles, surrounded with
the pneumonia, exist at the posterior part of the lung, the difficulty
of the diagnosis increases greatly, from the doubt created by the
seat of the disease.
And this is not all ; when the tuberculous affection, instead of
being confined to a limited space, is scattered profusely through
the whole parenchyma, as is so common in the acute phthisis of
children, the diagnosis is far from being clear. Thus, in those
cases of equally disseminated tubercles, without any surrounding
pneumonia or bronchitis, we have many times found no other phy-
sical signs than a rudeness of the respiratory murmur ; and if there
be bronchitis or presence of mucus, we have a mucous or subcrepi-
tous rale ; very nearly the same symptoms as in the simple lobu-
lar pneumonia. Now as this latter affection, as well as phthisis, is
the frequent successor of measles, we can, in such a case only
form our diagnosis upon the collateral evidence and the final pro-
gress of the disease. Suppose, in a case of hereditary predisposition
to tubercles, we observe, after measles, that the cough continues,
that for a month after there is still heard the mucous^rale and that
the child emaciates with an attack of fever, each evening ■ with
DIAGNOSIS. 51
these symptoms alone we might suspect the existence of tubercles.
If, however, after the measles in a healthy well constituted child,
there still exists a violent fever, cough, mucous or subcrepilous
rales, succeeded by an expiration and then bronchial respiration,
we might believe in a lobular pneumonia which has finished by
becoming general. We see, therefore, there are many cases where
error is easy, and we ought to suspend our diagnosis till after some
days' examination.
Finally in a last case, the difficulty of the diagnosis depends
no longer merely on the combination of the phthisis and the pneu-
monia, but lies entirely in the particular form of this latter affec-
tion. If, in fact, we recall the particular character given to our
first species, we shall recognise in them nearly all the symptoms of
phthisis arrived at its last degree. The cough, the colliquative
diarrhoea, the extreme emaciation, the paleness of the skin, the
infiltration of the extremities, &c, what are these but the collection
of symptoms assigned by all pathologists to the tubercular disease,
in its most advanced stage. Despite an appearance so deceitful,
however, the diagnosis will not be very difficult, since it must be
one of two things ; either the pneumonia will be simple, and then,
the physical signs bearing no proportion to the gravity of the con-
stitutional affection, will indicate that we have to do with a limited
affection of the lung, as a tubercular disease accompanied by such
grave general symptoms presents ordinarily physical signs indica-
ting 1 a considerable alteration of the pulmonary parenchyma, or
else the pneumonia will have passed to a generalisation and as-
sumed the lobar form, and the stethoscope will inform us that the
disease exists at the posterior part of the lung, is double, &c. &c. :
in a word, we shall recognise by it all the signs of a pneumonia.
The progress of the malady will also present various differences
between the two diseases ; thus, generally the diarrhoea precedes
the cough in the pneumonia, while in phthisis it appears at a
period more or less distant from the commencement of the disease.
And to conclude with the final difference, we will cite the age at
which both the affections are developed. Our first variety of pneu-
monia is most often met with in children of two and three years of
age, while at that period of life pulmonary phthisis is very rare.
CHAPTER IX.
PROGNOSIS.
The gravity of the prognosis varies with the age and the different
forms of the disease. It may be advanced, as a general proposition,
that a pneumonia is the more dangerous in proportion to the youth
of the patient. Our tables very manifestly prove this, and the re-
52 RILEIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
searches of MM. Valleix and Vemois, at the Hospital of the Enfans-
Trouves o-ive a further weight of evidence to this assertion. As
to the influence of the different forms, the pneumonias of our first
species are grave in consequence of the disease which they com-
plicate. They are, in fact, nearly necessarily mortal. Grounding
upon the experience of our predecessors, and upon our own in par-
ticular, we would call them always fatal, if it were not for a re-
markable case before us, of recovery in a child placed under the
most unfavourable circumstances.
The secondary forms of pneumonia are, at all ages, of an ex-
treme gravity: thus, of eighty-one pneumonias, complicating very
various diseases, observed in our service in lb37, seventy-seven
have terminated fatally. The pneumonias in the youngest chil-
dren, supervening upon a good state of health, or merely upon a
slight catarrh, most usually recover : eight patients, from three to
five years of age, have recovered from the disease under these cir-
cumstances. And. finally, the inflammation of the lung, in children
from five to fifteen years, occurring in good health, arrives, in the
immense majority of cases, at a happy issue. All the patients of
this latter category have recovered: this result, based on so few
facts, might be contested, if other observers (Gerhard and Rufz)
had not arrived at the same conclusion, after an examination of a
much larger number of cases.
A general prognosis from the study of the circumstances of the
developement of the disease being thus established, it remains to en-
quire if particular symptoms indicate, in any positive manner, a
greater or less gravity of the affection. The state of the pulse is one
to afford us the greatest aid. Its acceleration is generally in a direct
proportion to the intensity of the disease: but, in addition, at an
advanced period of the malady, we have observed a character
already mentioned, but upon which we would especially insist in
this connection, viz: the smallness of the pulse. Every time, when
this has been noted, death has not failed to appear in a few hours,
or a couple of days at the utmost. The cessation of the cough, the
chilliness of the extremities, the purple hue of the face, coincide
ordinarily with this smallness of the pulse, and announce a speedy
dissolution.
CHAPTER X.
TREATMENT.
The therapeutical is, without dispute, of all parts of a monograph,
the one meriting the most serious attention. The final end of all
medical research, it constitutes the only portion really practical.
TREATMENT. 53
Therefore, in the study of the treatment, we have not confined our-
selves solely to onr own observations, but have laid under contri-
bution those of our predecessors. Unfortunately, too often their
assertions are contradictory, and their opinions without proof.
In the hope that an examination of particular facts might throw
some light upon this present question, we have analysed, with a
special care, nearly ninety observations, inserted in different jour-
nals of medicine, or in the different monographs already alluded to:
but we have to regret the little fruit of our labour, in consequence
of the lamentable deficiency of detail.
In the interpretation of facts, as also in the estimation of the the-
rapeutic value of our observations, we have adopted the following
method : — after as complete as possible an assurance of the proper ad-
ministration of the remedy, we have endeavoured to appreciate its
influence upon the progress of the disease, and we have laid parti-
cular stress upon the period at which the treatment has been com-
menced. „
The comparative variations of the pulse and respiration, together
with the physical signs, have served us to denote the increase or
decrease of the disease. We have, besides, examined the action of
the remedy, considered both in the first dose, and after a continua-
tion of several successive days. And, finally, in the appreciation of
the final result, (death or recovery,) we have taken into the ac-
count, as an essential element, the nature of the pneumonia which
we had had to treat; for, if our details upon the subject of prog-
nosis be remembered, the reader will recollect the immense influ-
ence upon the termination of the disease exerted by the conditions
of its development.
With the exception of some particular medication, exacted by
special indications, the treatment has always been composed of two
parts : one common to all diseases, (hygiene,) the other special to
the disease before us: we commence with this latter.
The principal measures directed against the inflammation have
been, I. Bleeding; 2. Antirnonials ; 3. Derivatives applied to the
cutaneous system.
We shall first examine the effects of the separate employment of
each of these remedies, and then the influence of all combined.
Bleeding.
Opinions of authors vary much as to the influence of bleeding
in the pneumonia of children. Thus, some proscribe it absolutely,
while others make it the basis of their treatment. Some prefer
o-eneral, others local bleeding. It should be remarked, that those
employing the bleeding, dread to carry it too far, lest the patient
may never recover from the collapse. We have cited, however, an
observation (perhaps unique in science) of a child treated by the
formula of repeated venesection. A favourable issue, however, in
this single case would not induce us to dare to imitate such an ex-
54 RILLtET AND BARTtiE'Z. ON FNEUlMoNlA OP CHILDREN.
periment. It must be remembered, however, that the child, though
only aged two years, was in perfect health at the commencement
of the disease, and, therefore, in the most favourable situation : and
further, when we scrutinise the details of the case, we find the
amelioration to have commenced only the seventh day from the
invasion, that is to say, the bleeding does not appear to have sen-
sibly advanced the epoch of the usual resolution of the hepati-
sation.
Having just said that practitioners did not push very far the loss
of blood, we give here their usual method. In children from two
to four years, local bleedings are generally alone employed, either
by leeches or cupping glasses. At this age, twelve or fifteen leeches,
three or four times repeated, are the usual extent. In older child-
ren, they employ bleeding from the arm proportionate to the age
of the child and the intensity of the disease ; thus, in a child from
five to eight years, four to eight ounces of blood at once: in those
from eight to fifteen, eight to twelve ounces.
In some particular observations, this moment under our eyes,
(Gazette Medicale,) we noticed bleeding to nine ounces, repeated
twice, thrice, and four times in children from twelve to fourteen
years.
After this general indication of the methods of different prac-
titioners in the employment of this remedy, we will discuss the
efficacy of such a treatment. Here we shall find a wide difference
between the idiopathic and the complicated pneumonias. Ger-
hard thinks copious bleedings may be of advantage in the idio-
pathic pneumonia of children from six to fifteen years. He has
remarked the immediate effect to be a diminution of the intensity of
the general symptoms, (headach, agitation, oppression, &c.,) with-
out, however, any appreciable influence upon the duration of the
disease.
The analysis which we have made of different observations does
not comprise all these results: we find in many the bleedings, even
copious, to have had not only no appreciable effect on the pulse or
respiration, but also none upon the patient's general condition.
Thus, M. Blache has inserted, in the Archives de Medecine, (1837,)
several cases of pneumonia, in which no amelioration whatever
followed the loss of blood. Besides, we may make this general
remark, that the amendment in the symptoms succeeds rarely to
the first bleeding, but follows only the second or third, at a time
corresponding to the seventh and ninth days of the disease. We
may, therefore, establish as a principle, that, although of some ad-
vantage in idiopathic pneumonia, the utility of bleeding appears
restrained within very narrow limits.
If, now, we attempt an appreciation of its influence in the com-
plicated species of the disease, we shall be struck with its want of
influence not only upon the termination, which is nearly always
fatal, but also upon the progress of the disease, which undergoes no
sensible modification. If proofs are sought, we have only to o-lance
TREATMENT. 55
at the observations, by M. Blache, of pneumonia complicating
noopin^-congh, to read the reflections of M. Baudin on the treat-
ment of the disease after measles, or consult many other observa-
tions scattered in the different periodicals, and we shall be terrified
with the immense proportion of the mortality, and the complete in-
efficacy of the subtraction of blood.
We may add, in confirmation, that M. Becquerel, who made his
observations in a service where this mode of treatment was solely
employed, has never seen a case of recovery in the disease, com-
plicating a pre-existing- affection.
To give some idea of the action of bleeding, we will report suc-
cinctly the history of three of our patients, the only ones submitted
to this treatment. Their ages were two, five, and six years: in
the first two the disease was developed in tolerable health, in the
third it complicated a hooping-cough. In the first, (the child of.
two years ) on the sixth day of the disease, five leeches were ap-
plied to the right side, the bites of which furnished an abundant
quantity of blood. On the morrow there was a sensible ameliora-
tion, the pulse had fallen from 160 to 120; the bronchial respira-
tion and the dulness on percussion, which before occupied the
whole of the inferior lobe, were much scattered ; the coloration
of the countenance gave place to paleuess; a calm succeeded to the
agitation, <fcc.
The child of five years was bled, the sixth day., to six ounces,
when the pulse was 140, the respiration 36, and a bronchial respi-
ration existed in the middle third of the ri^ht lung: the morrow,
seventh day, the respiration was bronchial in both its times, the
percussion but slightly resonant in these points, the pulse 120,
respirations 44. Six leeches were applied to the right side. The
eighth day the pulse was 120, the respiration 34, and the bron-
chial respiration was heard in the whole height of the lung. The
ninth day, pulse 120, respiration 34, bronchial respiration limited to
the summit, with subcrepitous rale beneath. The tenth day, pulse
100, respiration 28, bronchial respiration at the summit, &c.
In these two cases there appears to have been some influence
exerled upon the progress of the disease. But it should be remarked
that if, in the first, the amelioration succeeded immediately the ap-
plication of the leeches, it was only definitive on the seventh day,
that is to say, at the very time when the pneumonia, supervening in
good health, has the greatest tendency to assume, of itself, a favour-
able change.
In the second, the resolution of the pneumonia appeared only the
ninth day, despite the bleedings of the sixth and seventh. And as
to the final result, (recovery,) we must recollect that our patienls
were both placed in very favourable circumstances, and in a class
of the disease nearly always terminating in health.
Our third child was not in the same condition : the pneumonia
appeared in the midst of a hooping-cough, or rather of a catarrh,
with very intense paroxysms, and the disease had already deter-
56 RILl.IET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
mined a formidable constitutional reaction when the inflammation
of the lung was developed : so great a loss of blood, (one bleeding
of six ounces, and twenty-two leeches applied at different times,)
exerted no influence upon the pulse, respiration, or march of the
disease.
Antimonials — Tartar Emetic.
In the examination of the effects of antimonials, and of the tartar
emetic in particular, we were obliged, from the complete want of
published facts, to have recourse solely to our own observations.
We find, it is true, many cases in authors, entitled cure of pneu-
monia by tartar emetic, but in nearly all, bleeding - has been em-
ployed in concert, constituting the mixed method, of which we
shall soon have occasion to speak.
Nine of our patients took the tartar emetic carried to a high dose.
Six of them were aged from two to six years, three from eleven to
fourteen. The portion given to the youngest contained three and
four grains. 1 in five ounces of the vehicle; for the older, the dose
was five to six grains. They took a spoonful every two hours, and
when the first produced vomiting, they delayed the following doses:
in general, a tolerance was quickly established, though sometimes
we had to encounter vomitings, and, in one case, a somewhat pro-
fuse diarrhoea, lasting several days.
The vomitings seldom endured after the first dose, or, in general,
they were not numerous, and ceased sometimes even under an in-
creased dose of the remedy. We have never seen any accidents
from this medicament, except in two cases of a pustular inflamma-
tion of the fauces. This inflammation, due entirely to the local
action of the remedy, and so frequent in the adult, has been ob-
served in nearly all the patients of this year, treated with the tartar
emetic: it presents no particular gravity, and yields usually in
young children, as well as in older subjects, to the simple emol-
lients.
What has been the influence of the tartar emetic upon the termi-
nation and the principal symptoms of the disease? Of nine patients
four have recovered, and two of these under rather unfavourable
circumstances: thus, one had a pneumonia after small-pox, the
other a double pneumonia, complicating the measles. Our third
was a child of three years, attacked from the commencement with
a slight catarrh and a chronic eczema : and, finally, the fourth case
of recovery is a young girl of eleven years, of a scrofulous consti-
tution, but otherwise in good health at the commencement. Two
of these commenced the treatment the first day, the other two at
the sixth day only. The whole quantity taken by each has varied
from sixteen to twenty-four grains. In these four patients the
1 In giving the amount of doses of medicine, the quantity per diem is in-
tended, this being tlie form of prescription in the Parisian hospitals. P
TREATMENT.
57
emetic tartar appeared to exert some influence upon the pulse and
upon the respiration, but this influence has not been in all the cases
durable, and in three of the cases it manifested itself nearly at the
same epoch in all, viz: from the seventh to the ninth day of the
disease. As to the patients who succumbed, they were placed in
the most unfavourable circumstances: three were already attacked
with measles and with typhoid fever, and the remaining one was a
child of two years, with a double pneumonia complicated with a
pleuritic effusion. We have, however, been able to remark a de-
cided influence upon the pulse and respiration, even in those of
the fatal cases, where the dose was a little elevated : but there
was no decided effect upon two patients who took only six grains.
If we sought to draw any general conclusions from this small
number of facts, we should say, but with reserve, from the small-
ness of our numbers, thai the tartar emetic may be employed with
success in the child; that there is no danger in a somewhat ele-
vated dose ; that the tolerance is generally easily established ; that
the gastro-intestinal accidents give little cause of fear ; and. finally,
that this medicament appears to act more directly Upon the puhe
and respiration than upon the hepatisation itself.
The combined Method of Treatment, Bleeding and the Tartar
Emetic.
After this attempt at a separate estimation of the value of bleed-
ing and the tartar emetic, we will examine their combined influ-
ence upon the disease before us. We have discovered in various
authors thirteen cases, giving somewhat circumstantial details upon
this mode of treatment: In all these cases the tartar emetic has
been given after more or less copious bleeding, and at some dis-
tance" from the commencement of the disease. All the patients
thus treated and attacked with idiopathic pneumonia, (aged from
nine to twelve years,) have recovered, with the single exception of
one, who succumbed, with a eangrene of the mouth supervening
upon the pneumonia. Two children, in whom the pneumonia was
developed around a tuberculous affection, have died although in
one of them there took place a very sensible amendment of the
symptoms after the first dose of the antimony. As to the influence
of this method of medication upon the progress of the disease, it
has appeared to us, after an attentive perusal of the foregoing ob-
servations, that the combination of the two methods exerts a more
decided influence upon the general and local symptoms than the
employment of either one separately. Thus, although in general
the amelioration appears from the seventh to the ninth day as in
the cases treated by the tartar emetic simply, we find in two or
three cases an amendment of the symptoms on the hfih or sixth
dav : and more than this, in all the cases, even in those terminating
fatallv a diminution of- the pulse and respiration succeeded the
first dose of the medicament, whatever was the period of the dis-
58 RILLIET AND BAItTHEZ ON PNEUMONIA OF CHILDREN.
ease at which it was employed. Three of our patients were sub-
mitted to the com'aned treatment of hleeding and antimonials: all
three were bled once or twice, and took besides, one the tartar emetic
another kermes mineral, and the third both the tartar emetic and
the kermes. The tartar emetic was always given in the dose of
one or two grains in a large quantity of water as vehicle, and
determined numerous vomitings. The three patients submitted to
this treatment recovered, but the pneumonias were all idiopathic
and the amelioration took place from the seventh to the ninth day!
The facts already published are by no means sufficiently nume-
rous to decide the grand question of the mode of action of the tartar
emetic. Is it by absorption, or does it merely determine, by the
vomitings, a salutary revulsion upon the digestive canal? Both these
hypotheses are, perhaps, just; in some proof of which, on the one
h;md, the emetic tartar carried to a large dose, without vomiting, ap-
peared to have exerted a happy influence upon the disease— while,
on the other hand, a rapid amelioration followed its employment in
doses producing vomiting in two or three patients, whose cases
are now before us. In several of these cases, the analysis of which
forms the basis of this article, we see that the dose of the emetic
was sometimes carried to a great extent— thus, a child of fourteen
years took, in all, one hundred grains, and even as high as ten
grains, in the twenty-four hours; another, aged nine years, took
daily from six to eight grains, &c. &c. In aU the.se cases not the
least accident has resulted.
White Oxide of Antimony— Pulois Anlimonialis.
Eighteen of our patients were treated with this' medicament ; ten
in large doses, and eight in small. We have but little to remark
upon these latter cases, as the remedy was never given at the com-
mencement, nor throughout the whole disease. In these eight,
the dose per diem varied between ten and eighteen grains in four
ounces of vehicle, to which was added 3ij. or #1 j. ofsymp of dia-
cod.um (syrup of poppies.)' All these children, except one, are
in our first d.v.smn-that is, pneumonia supervening upon some
chronic affection. Two of these recovered, but this cannot be
attributed to the remedy ; in one case it was not commenced till
he ninth day, when the pneumonia already tended to a resolution,
whilst ,n the other, a child of eleven years, attacked with small-
pox,) it was administered for only a single day
Of the other ten, we must eliminate two, who, dying the day
after their entrance of very extensive pneumoniae, took, conse-
quently, only one potion of the remedy. The pulvis antimonSL
was administered to children between two and five years of age!
1 The syrup of poppies of the London Pharmmnnm;,
United States Dispensatory, resembles the syrup ? En ? ^Z '. n lh *
to be considered as identical with \t.—P. YlP diac °dium sufficiently
TREATMENT.
59
One other, aged six and a half years, who was attacked with a
general capillary and vesicular bronchitis, cannot, consequently,
be included among the pneumonias.
The powder was given in emulsion or mucilage, in the dose (for
children of two and three years) of half a dram in the twenty-four
hours, carried as high as a dram and a half, or even two drams.
Children of four and five years took from one up to three drams,
or even half an ounce.
Of these eight patients only one recovered, who had a lobar
pneumonia involving the whole lobe. Of the others there was,
perhaps, only one susceptible of recovery, judging- from the pro-
gress of the disease, the pathological anatomy, and the absence of
complication. The influence of this medication has appeared al-
most nothing upon the pulse and respiration, whether after a single
dose, or many days' employment : if sometimes the pulsations did
diminish in number, at others they increased, or remained the same.
The same remark applies to the respiration, the variations of which
presented no accordance with those of the pulse. But, upon the
progress of the disease its influence was still less— in almost no
case was there a sensible amelioration. In the only patient who
recovered it was after the sixteenth dose, (the eighth day,) that the
alteration for the better manifested itself, and the disease lasted, in
all, eighteen or nineteen days, which would seem to indicate no
abridgment from the pulvis antimonialis. However, the following
happened in one of our patients : after the first dose, the pulse in-
creased from 120 to 150, the respiration from 46 to 50, the physical
signs remaining the same; but, after four days of its administration,
an amelioration was declared in all the symptoms, the pulse fell
30 beats, and the inspirations instead of 50 were 44 : and the aus-
cultation confirmed this great amelioration. The dose of the
powder was diminished, and the next day all the symptoms re-
appeared as violent as ever. It was increased again, the pulse fell
to 100, the respiration to 34, without any sensible amelioration in
the physical signs: the amendment, however, did not continue;
all the symptoms were soon aggravated ; and death did not delay
its appearance. •
In this case, if the pulvis antimonialis really did exert no mani-
fest influence, at least the coincidence between the administration
of the remedy and the amelioration of the symptoms is a little re-
markable. . ... , ...
We have never observed any action of this powder upon the
digestive tube, nor any accident from its employment. It must be
allowed to have the power of slightly exciting the gastric mucous
membrane, since in two of our patients treated the one with high
and the other with small doses, and in whose stomachs, at the
autonsv we found some of the powder, there existed patches of red-
ness, more or less vivid, at those points where it was in contact with
the mucous membrane.
60 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
The different observations published upon the employment of the
antimonial powder in the pneumonias of children do not at all con-
tradict the results at which we have arrived. In many of them we
can discover no influence of the remedy upon the pulse, respiration,
or the inflammation itself; and in many, where its influence upon
the progress of the disease is vaunted, it would seem impossible to
decide whether the amelioration was due to the remedy, or whether
nature herself had not performed the cure, the precise period of the
commencement of the disease not being indicated in the observa-
tions.
It must be remembered that all our patients except in the case
of recovery, were in the first category, that is, of pneumonias ac-
companying some other grave disease, which are very universally
fatal.
Precipitated Sulphuret of Antimony. — Kermes Mineral.
We have no where found any detailed observations upon the
use of the kermes mineral in the pneumonia of children ; we must
therefore have recourse solely to our own observations. Fifteen
patients were treated by this medicament : of these we must elimi-
nate four, to whom it was given in a small dose, as adjuvant merely,
and not forming the basis of the treatment, and three others, in
whom the disease was already too advanced to hope for any relief,
death supervening the day of the commencement of the treatment.
The remaining eight patients were aged between four and four-
teen years, embracing therefore pneumonias of all the ages and
species. The kermes was administered in doses of one and two
grains to commence ; and was carried successively to twelve, fif-
teen or even seventeen grains in the twenty-four hours, augmenting
a grain about every visit ; of these eight patients, three recovered,
from an inflammation of all one lung, or a lobular pneumonia.
Among the other five, there was only one perhaps capable of re-
covery, since he alone had no primitive grave complication : his
pneumonia was well marked lobular, but so extensive at the day
of entrance, that a fatal termination' was prognosticated from the
commencement.
If now we attempt to seek the influence of the kermes upon the
pulse, respiration, and stethoscopic signs, we find these three
symptoms in some cases increased, in others diminished, and in
others remaining stationary. The general idea, however, which
remains after an examination of the result of the treatment in all
these patients, is that the kermes has exerted a favourable influence
more often than otherwise, and therefore that it is a tolerably effi-
cient remedy. But if we come to the analysis of each separate
fact, we find that the cases, where the symptoms were aggravated
after several days of treatment were precisely those where the
pneumonia was of our first species, and therefore almost necessarily
fatal. Among those on the contrary, terminating in health, are
TREATMENT. 61
found the idiopathic and lobar forms, free from all complication,
where, according to Gerhard and Rufz, recovery is certain what-
ever may be the treatment. Besides a certain number of our pa-
tients have entered when the disease had reached its maximum of
intensity, and when an amelioration after the first dose of kermes
is rather to be attiil.nted to the arrival of the disease at its natural
climax. Thus a child of four years was submitted to our observa-
tion the seventh or eighth day of an idiopathic lobar pneumonia
with pure bronchial respiration ; he took a grain of kermes and the
next day he had the returning crepitous rale, and two days after a
diminution of all the symptoms. Is the amelioration to beattrihuted
to the kermes taken these three days, or to the natural progress of
the disease? The latter appears to us the more probable. Observe
in fact, that in all our cases of supposed beneficial effects of reme-
dies, it is always at the same period of the disease that the amelio-
ration manifests itself — from the seventh to the ninth day — we
cannot, however, refuse to admit some influence to the kermes, as
we have established its power in diminishing the pulse and respi-
ration in several cases, both immediately after the first dose, as well
as after several days of treatment, in patients gravely affected, and
attacked with complications finally resulting in death. We possess,
besides, one case of recovery in a lobular pneumonia after measles,
under the sole use of the kermes: and this pneumonia although
exempt from any unfavourable complication, was not the less
grave, considering the cause to which it owed its birth.
In some cases the kermes has been administered at a very high
dose, especially for a child. Seventeen grains are more than is
habitually given loan adult; a dose apparently so enormous has
had no unpleasant influence upon the digestive organs ! Here is the
result of our experience.
Our patient, who took the seventeen grains, and who recovered,
presented before the administration of the kermes, some symptoms
referable to the digestive tubes — bilious vomitings, diarrhoea, and
abdominal pains. These symptoms underwent no augmentation
under the increasing doses ; after about fifteen days they ceased
altogether, although the patient was then taking thirteen or four-
teen grains in the twenty-four hours.
In another who took fifteen grains and who died, we observed
before the first dose the same symptoms connected with the intes-
tinal canal ; but these symptoms increased with the inflammation
of the lung, and at the autopsy we found an inflammation of the
gastric mucous membrane, slight in extent it is true, but very well
maiked, especially where there yet remained a portion of the
kermes. We have never observed any other accident requiring a
suspension of this treatment.
To conclude the history of the kermes mineral, we give a suc-
cinct extract from the observation of one of our patients treated by
bleeding the tartar emetic and this latter substance; the reader
may thus judge of the combined action of the three.
62 rilliet and uaktiiez on pneumonia op children.
It is the case of a child aged ten years, at the fifth day of a pneu-
monia of the lower half of the left lung, with bronchial respiration,
absence of rale, and dulness upon percussion. Infusion of mallows,
syrup of gum ; with gr. ij. tartar emetic, looch, 1 bleeding to eight
ounces, diet. The tartar emetic thus administered produced fre-
quent vomiting, and on the morrow the pulse had augmented from
122 to 152; the inspirations had diminished from 82 to 62, the
bronchial respiration had extended a little superiorly, but a crepi-
tous rale was heard after cough inferiorly. This first prescription
had at once augmented and ameliorated the gravity of the symp-
toms. (Infusion of mallows, syrup of gum, looch, with kermes gr.
ij. the half of an emollient enema, diet.)
The day after this first administration of the kermes, seventh
day of the disease, diminution of the bronchial respiration, more
abundant rale, the inspirations have fallen from 60 to 36, the pulse
from 132 to 96. The treatment is continued with the addition only
of a bouillon. But on the eighth day the rale had disappeared, the
bronchial respiration was in the same extent, the pulse was 150,
the respiration 36. (Emetised whey, gr. ij. ; blister to the legs.)
The following day the bronchial respiration had extended, but
there was but little ia!e ; respirations 50, pulse 132. This day the
kermes was resumed in a dose of two grains, with one half an ounce
of syrup of poppies. The disease continued augmenting, till the
thirteenth day, when the patient took five grains of kermes. But
the fourteenth day, the bronchial respiration was less, the crepitons
rale of return again appeared every where.
From this moment the patient continued improving until com-
plete convalescence, and on the nineteenth day the respiration was
pure on both sides. The kermes was continued a few days after
this happy result. We see, in this case, only a dubious salutary
influence of the bleeding and tartar emetic, as it was only on the
seventh day of the disease that an amelioration took place ; the
kermes was not sufficient to continue this improvement, and a re-
lapse was the consequence. The tartar emetic was again given,
with a similar result, and it was only on the fourteenth day of the
disease, the sixth of the relapse, that the patient was definitively
belter under the influence of the kermes. Should we in this case
attribute the cure to the remedy, or shall we think that the disease
has followed its own course without any regard to its influence?
Derivatives to the skin — Vesicatories.
Vesicatories have been employed in conjunction with the other
remedies and nearly always at an advanced period of the disease.
They have been applied either to the diseased side or to the ex-
■ Looch is an emulsion of almonds and sugar containing some gum traga-
cantli: it is entirely demulcent.— P. & b
TREATMENT. 63
tremities. They have not appeared to modify the course of the
affection, and they have caused the patient such inconvenience, as
ought to proscribe their employment. In fact the skin of the pos-
terior part of the thorax, in contact with the soiled linen, com-
pressed by the projecting ribs, excavates and ulcerates, in a manner
very painful and difficult to heal, and adding still more to the
gravity of the prognosis. It is especially with regard to the pa-
tients in our first category that we have made this remark, which
besides has not escaped M. de la Berge.
These remarks upon blisters are equally applicable to the Bur-
gundy pitch plasters sprinkled with the tartar emetic, which have
been applied to some of our patients.
We should not forget among the revulsives, the cupping glasses
which we have seen applied in some cases. Ordinarily dry cup-
ping only is employed in the younger children ; in the older, how-
ever, the scarificators were added, thus answering the indications
of a local bleeding, and a derivative. The cases of the employment
of these means are too few to estimate their therapeutic value.
In concluding this history of the different active agents put in
force against the pneumonia of children, we will still revert to a
general remark upon which we have always insisted, viz : that the
first signs of amelioration appear in nearly all the cases, at the same
period of the disease, from the seventh to the ninth day, whatever
be the treatment employed. This fact tends to lessen greatly the
influence of remedies, not upon the termination (we put aside this
view of the question) but upon the course of the disease. It proves
also that pneumonia has a period of increase which it must fulfil,
and that the different medications directed against it are perfectly
powerless in arresting its ascending progress: — the proof of this is
in the fact, that in cases where no treatment has been employed,
an amelioration has not been the less manifest at this same period
of the disease. Of this we have one remarkable example.
The second part of the treatment now requires our attention,
consisting of emollients, sedatives, and at times of tonics. The
usual beverage was infusion of mallows sweetened with syrup of
gum; in addition, usually, julaps containing from 3ij to gss of
syrup of poppies. When the child was debilitated by a preceding
disease, or when the constitution was feeble and delicate, there was
added §ss of syrup of cinchona.
Whenever any other disease, complicating the pneumonia, pre-
sented any pressing indication, it was combated by the appropriate
remedies. v.-
The young patients were rarely submitted to an absolute diet. 1
In those of the first category, whenever there was appetite, food
was o-ranted. In the younger patients attacked with acute pneu-
monia, the anorexia being usually complete, all aliment was with-
1 The French diite is here and in all other places rendered literally,
as meaning the deprivation of all nourishment of whatsoever species.— P.
64 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
held for the first three or four days of the disease — but immediately
on any appearance of appetite, the light soups, milk, and bouillon
were prescribed. Young children support badly an absolute diet,
and the disease is aggravated by many successive days' deprivation
of nourishment. Older children were dieted, but as soon as any
amelioration appeared, they were allowed bouillon and soup.
It is very difficult to lay down general rules in therapeutics-
nevertheless if it be allowed to us to point out a plan of treatment
for the pneumonia of children, we would recommend the following:
1. In a pneumonia supervening upon a chronic affection, and
assuming itself the character of a chronic disease, no active medi-
cation should be directed against it, but an attempt made to modify
the general health. Particular attention should therefore be paid
to hygienic precautions, avoiding the continued decubitus ot the
child upon the back— prescribing the most absolute cleanliness, &c.
As general treatment we would advise the use of light tonics inter-
nally—and, above all, (the appetite still remaining in most cases,)
we would prescribe fortifying and nutritive aliment, in a small com-
pass. The diarrhoea is not to serve as counter-indication, for the
diarrhoea of children by no means always depends upon an inflam-
mation of the digestive tube : most generally it is dependent upon
a softening of the mucous membrane, which has more analogy
with anaemia than inflammation. As a tonic externally, the sul-
phur bath might be prescribed, from which M. Jadelot thinks he
has obtained some success.
2. If the pneumonia be present as complicative of a pre-existing
disease, we would not have recourse to the subtraction of blood of
which we have already demonstrated the want of success— we should
prefer the treatment by the tartar emetic, since in a certain number
of cases recovery has followed its employment. We should not
fear to carry this remedy to a very high dose proportionate to the
intensity of the inflammation, and despite any slight contraindica-
tions on the part of the intestinal canal.
3. And finally, if the pneumonia were idiopathic, we would em-
ploy the combination of bleeding and the tartar emetic we would
however, not carry the loss of blood to any great extent always
proportioning it to the gravity and extent of the inflammation
OBSERVATIONS AND TABLES. 65
OBSERVATIONS AND TABLES.
We at first intended to append at the end of our work the greater
part of the observations, which have served for its basis : but this
project we have abandoned, as giving 1 to our little undertaking a
volume too considerable. We have prefered to give only facts suf-
ficient to prove the principal assertions we have thus far advanced.
Thus, there will be found, in the following pages, examples of the
different forms, which the pneumonia assumes, of the two periods
observed in it, of the different alterations of the respiratory sound,
of the numerous lesions of the pulmonary parenchyma, &c. &c.
If we have not quoted an example of idiopathic pneumonia in
children from five to fifteen years of age, it is because the periodical
collections abound with cases of this nature, and we are desirous
of pointing out only facts the least known.
At the end of our observations, we have placed two tables of the
pathological anatomy, representing the comparative frequence of
the different forms of the pneumonia, as well as of the different
other lesions of the lung, which most usually complicate the in-
flammation of the parenchyma.
OBSERVATION I.
Child set. three years. Constitution not strong. Acute pneumonia. Two
well marked periods. Treatment by the tartar emetic. Effect upon the
pulse and respiration. Amelioration of the local state on the seventh day.
Final convalescence the twelfth. Disappearance of all rale the twenty-
fifth day.
Vaillant (Eliza) 8bt. three years, has been under treatment for
more than a month in the ward St. Genevieve, for a diffused
chronic eczema of the trunk. Ten days before entrance into the
acute ward, she had commenced to cough, but her catarrh was so
slight as not to oblige her to take to her bed. Oct. 12, she was
suddenly attacked with fever and increase of cough. The 13th,
she was brought to No. 2, ward St. Anne, where we saw her at 3
P M., in the following state :—
Constitution not strong : remains of the eczema on various parts
of the body ; chest well formed. Decubitus dorsal, eyes closed,
cheeks coloured, skin burning, pulse 160, full and regular Inspi-
rations 64, without dilatation of the ala nasi: the child is re-
markably somnolent. In front, on both sides, the respiration is
17— a nl 5
66 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
strong and pure. Behind pure, in the whole of the left side and
the summit of the right ; but in the middle part of the right side it
is obscure, and below, in two fingers' breadth, bronchial — the bron-
chial character is especially marked in the slight cry that accom-
panies the expiration. The resonance on percussion is diminished
at the right base ; it is normal in the left. The cough is rare, with-
out expectoration ; the tongue is quite moist, with a slightly white 1
coat : abdomen distended and tympanitic : no stool since entrance.
Prescription. — Sweetened infusion of mallows for drink.
Take of Tilled 1 water, 3iv.
Syrup of poppies, £iij.
Tart. ant. and potass, gr. iij.
Syrup, §j.
This prescription, given by spoonfuls, determined no vomiting,
but three or four loose dejections, and it was all taken on the 14th,
at three P. M. Up to this time the febrile symptoms continued
unabated; pulse 160, respiration 64. The hepatisation appears to
have advanced. The percussion is flat in a greater extent than
yesterday ; the respiration is obscure on the right in the two in-
ferior thirds : in a strong inspiration, a bronchial respiration is
heard in various scattered points of the inferior third. The skin
is excessively hot. The prescription is continued, with an increase
of the tartar emetic by one grain. The next day, (the 4th,) three
quarters had been taken at noon without vomiting. The skin is
less warm than yesterday; pulse 144, respiration 36. The child
opens her eyes, commences to speak, and asks to sit up in bed; the
tendency to somnolence has disappeared. This amelioration of the
general symptoms, however, is unaccompanied by any propor-
tionate change in the physical signs, as the respiration continues
clearly and distinctly bronchial in the two lower thirds of the right
lung, with flatness in the same space, and a subcrepitous rale at
the summit. The same prescription is continued ; the tolerance is
perfect, and the 16th the child's state is stationary. The 17th, the
child has now taken in all fifteen grains of the tartar emetic, with-
out any vomiting ; the pulse is 120, the respiration 36. The bron-
chial respiration is present in the whole of the right lower lobe,
and at intervals, after cough, there are heard some explosions of
crepitous rale excessively fine. To-day the tartar emetic is omitted,
being replaced by a julap of poppies. The 18th, at seven A. M.
the child is in a peaceful slumber ; pulse 120, respiration 40, equal.
The bronchial respiration ceases to be heard, except at the inferior
angle of the scapula ; below this point, after cough, there exists the
crepitous rale, excessively fine. 19th, pulse 126, respiration 28;
same physical signs. 20th, pulse 116, respiration 28; the bron-
1 Tilleul is the Tilia Europea: no corresponding preparation is found in
the American Pharmacopoeia. Its real nature is unimportant, bein<* merely
used as a pleasant vehicle. — P.
OBSERVATIONS AND TABLES. 67
chial respiration has entirely disappeared, together with the rale,
only the respiration is accompanied by a sonorous rale posteriorly
and interiorly on the right, and the percussion is a little less reso-
nant than in the correspondent parts of the left lung.
23d. All trace of the flatness has disappeared f pulse 104, but
there exists posteriorly a somewhat abundant subcrepitous rale.
This rale persisted until the 5th of November ; but the convales-
cence may be considered as established on the 23d of October.
Remarks.— This observation is a fine example of acute pneu-
monia in a child of three years. With the exception of the expec-
toration, there existed the greater part of the symptoms of the
adult — acceleration of the pulse and respiration, "the stethoscopic
signs, and flatness on percussion. The two periods which we
have signalised in the pneumonia of children, from two to four
years, are here well defined. Our young patient had coughed for
ten days, but this slight apyretic catarrh did not prevent his run-
ning about all the day in the wards; when suddenly and simulta-
neously there supervened the acceleration of the pulse and the
respiration, which marked the transition to the second period.
Thirty hours after the commencement of the disease, the bronchial
respiration had already manifested itself, but in a limited space.
After this it was heard from the base to the summit of the lung,
and followed the same course as in the adult. Jn this case, there-
fore, we have, very probably, had to do with a pneumonia of the
lobar form. The bronchial respiration offers the character common
to that of children, viz. especially marked in the expiration. The
tartar emetic appears here to have had a manifest influence upon
the pulse and respiration. The fourth day, after the administration
of six grains, the pulse was diminished by 16, and the respiration
by 28. The sixth day, fifteen grains had been taken, and the pulse
was still further diminished by 24 ; and, finally, on the seventh
day we establish a manifest amelioration of the local state, and on
the ninth the bronchial respiration had entirely disappeared. Our
patient might be regarded as cured on the twelfth day of the dis-
ease, although it was not till the twenty-fifth that the last traces of
the rales had disappeared.
OBSERVATION II.
Child of two years.— Generalised lobular pneumonia on the left, with a
pleuritic effusion.— Simple lobular pneumonia on the right.— Two well-
marked periods. — Duration of the catarrhal period one month. — Of the in-
flammatory five days.— Access of suffocation, with the supposed appear-
ance of the pleuritic effusion.
Aliot, (Irma,) aet. two years, entered 24th November, 1824, the
Hospital of Enfans Malados, and was placed No. 2, ward Saint
Anne.
The persons who brought her, stated her to have been sick three
weeks, with anorexy, a slight diarrhoea, and cough. Submitted to
68 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
our observation November 25th, we found the following : Consti-
tution feeble, skin delicate, eyes black ; impetigo of the hairy scalp.
The dentition is not complete, the canines of the lower jaw are still
wanting; the child is always with her fingers in her mouth, as if
suffering with her teeth; countenance natural; skin not hot;
respiration 28, pulse 112. Percussion everywhere resonant. Be-
hind and before there is heard a combination of the sonorous and
large mucous rales ; the cough is rare ; the expectoration nothing.
Tongue moist, abdomen a little distended, but indolent; no di-
arrhoea.
Until November 30th, the state of the child remained the same.
Auscultation, practised every day, gave nothing but the same rales,
and there were no symptoms of reaction. The 30th, in the morn-
ing, the pulse was found accelerated as well as the respiration;
pulse 160, vibrating ; 52 inspirations. Persistence of the same
rales on both sides posteriorly, but more especially on the left. Per-
cussion less resonant at the left than right base.
December 1. Skin hot. pulse trembling, 180; respiration 60, un-
equal, with dilatation of alee nasi. Posteriorly, in the two inferior
thirds of the left lung, bronchial respiration, with percussion still
less resonant than yesterday; on the right, persistence of the mu-
cous rales, with diminution of the resonance, (julap of poppies, 3ij.)
Dec. 2. Pulse 164, still small and trembling ; respiration 60, irre-
gular. The respiratory murmur is not sensibly modified since
yesterday ; however, the mucous and sonorous rales, heard in the
right back, are replaced by a subcrepitous rale in the expiration:
the inspiration is rude at the summit, (tartar emetic, gr. iv. ; dry
cupping on the left side.) At four P. M. the child was found at-
tacked with an access of suffocation, the face purple, the oppression
extreme, and death appeared imminent.
On the morning of the 3d, our young patient was, however, still
alive ; pulse and inspirations as yesterday : countenance pale, skin
of the body moderately warm, of the extremities cold. The bron-
chial respiration has extended to nearly the whole of the left back.
The flatness on percussion is complete; on the right, at the level of
subspinal fossa, very distinct resonance of the cry, without any
bronchial respiration ; inspiration rude, subcrepitous rale in the
expiration, percussion resonant. The cough has ceased ; three
quarters of the potion already taken have produced no vomiting,
but two or three loose dejections. In the course of the day the con-
dition of the patient continued to aggravate, and he succumbed the
4th of December at midnight.
Autopsy thirty-four hours after death-weather fine and dry.
vib^es ema% *~ BOdy WeH f ° rmed; n ° cadave "c stiffness; no
2&arf. -Calvaria strongly adherent to the dura mater- arach-
noid smooth, transparent. Considerable quantity of Terosity m the
OBSERVATIONS AND TABLES. 69
subarachnoid tissue ; cerebral veins injected ; the brain, except a
somewhat excessive quantity of the bloody points upon incision, is
in the normal state.
Neck. — Larynx and trachea healthy.
Chest. — The right lung presents at the base some loose cellular
adhesions. The left pleura contains a glassful of purulent serosity,
and is covered with false membranes, soft, yellowish, and of about
an eighth of a line in thickness.
The right lung is supple, rose coloured in its greater part, but
in its middle posterior third, (base of the superior, and summit of
the inferior lobe,) it is violet coloured externally, and an incision
reveals the presence of a considerable number of scattered points of
a variable size, where the tissue of the lung is red, friable, and sink-
ing when placed in water, (lobular pneumonia.) The rest of the
lung is healthy, except the summit, which contains a tubercle the
size of a small nut. The bronchi of this lung contain a spumous
liquid, and are a little red, without, however, any alteration of
texture.
Left lung. — The upper lobe is supple, rose coloured, containing
neither tubercles, nor points of hepatisation ; the lower lobe violet
coloured externally, marbled red and gray in an incision which is
smooth, friable, granulated upon tearing, not floating upon the sur-
face of water, either in separate pieces or in totality. This alteration
occupies the whole lobe, and no single lobule remains unaffected
in the midst of the general disease. The bronchi of this lobe are
of rather a vivid red ; not dilated.
The pericardium contains no serosity. The heart, carefully
measured, is of normal dimensions; the auricles contain numerous
yellowish coagula.
The abdominal organs, examined with the minutest care, present
no appreciable alteration, except a slight injection of ten or twelve
of the patches of Payer, without softening.
Remarks. — We find, also, in this observation our two periods of
the disease well marked. After a catarrh of about a month's dura-
tion, the symptoms of which we were enabled to appreciate, the
disease commenced by a rapid acceleration of the pulse and respi-
ration, and what is very remarkable, the percussion revealed to us
the sio-ns of a pneumonia before the auscultation had thrown any
light upon the affection. The access of suffocation, taking place
thirty hours before death, appears to us to have coincided with the
effusion. In probable proof of which, there is, on the one hand,
the increase of the dulness, which, from being only relative, be-
came complete ; and, on the other, the lung was not found flattened
ao-ainst the spine, as if the pneumonia had been anterior to the
pleuritic effusion. We must not forget, also, the resonance of the
cry the subcrepitous rale, and the rudeness of the respiration,
which put us upon the diagnosis of a lobular pneumonia of the
rio-ht side, which was confirmed by the autopsy. And, finally, we
remark, in the left lung a well characterised generalised lobular
70 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
pneumonia, a tissue marbled with gray and red, the rapidity of the
hepatisation having almost destroyed any isolated hepatised lobules;
the lobules of disease which we met in the right lung are sufficient
to justify this idea.
OBSERVATION III.
Child of eighteen months. Lobular pneumonia slightly generalised, super-
vening on a chronic enteritis. Absence of constitutional symptoms nearly
complete. Death in the last degree of marasmus. At the autopsy, a
generalised lobular pneumonia of the right, simple lobular of the left lung.
Dilatation of the bronchi.
Haering, ast. eighteen months, was brought to the hospital, Oc-
tober 9, 1838. Born of healthy parents, she was put to nurse im-
mediately, where she remained till the age of eleven months, when
she was returned in perfect health. Two months before her en-
trance at the hospital she was attacked with diarrhoea and vomiting.
Admitted into the wards in the middle of September, she went out
after a short stay, but returned in October for the same complaints.
October 10, she was in the following state : —
Eyes blue, hair blond, constitution feeble, dentition incomplete,
the canines wanting. Countenance natural, sitting up in bed. The
cheeks are cool and moist, the extremities cold and purple; 40 un-
equal inspirations, pulse with difficulty counted. The respiration
is perfectly pure, and the percussion resonant in front and behind ;
the thirst extreme, the tongue moist; the surface of the abdomen
purple, tense, resonant, indolent; abundant yellowish diarrhoea ;■
appetite still preserved. No cerebral symptoms. Until the 2d of
November there appeared no change, except a constant and great
emaciation. The diarrhoea is as abundant, and the respiration re-
mains perfectly pure ; (the auscultation was daily.)
November 2. In the right back the respiration is a little more
feeble than in the corresponding parts on the other side ; here and
there are heard some slight cracklings ; no symptoms of constitu-
tional reaction.
Nov. 5. On the right back, large, moist, and mucous rales at the
summit; below, respiration obscure, and percussion a little less re-
sonant at the base than on the opposite side. Pulse 140, skin
slightly warm, no dilatation of a!a3 nasi; for the first time a
slight cough. From the 5th to the 10th no change.
Nov. 10. The cough is increased, the pulse insensible, respira-
tion 52 ; at the right base, for the width of two fingers, bronchial
respiration in the little dry expiration succeeding the inspiration;
above, respiration strong ; on the left, expiration exaggerated ; the
percussion is not resonant at the right base.
Nov. 13. Pulse still insensible, respiration 32, without dila-
tation of alas nasi; in the whole right back moist subcrepitous
rale, resonance of the cry at the base ; on the left, sonorous rale ■
OBSERVATIONS AND TABLES.
71
same state of the percussion. The face is yet paler than before ;
the emaciation extreme ; abdomen and limbs are covered with
ecchymoses, and the extremities oedematous ; diarrhoea still persists ;
the cough is rare, and only when the child is made to sit up.
Nov. 14. Pulse still insensible ; pulsations of heart distinct, 120 ;
respirations 32 ; in front, the respiratory murmur is strong and
pure ; on the right back subcrepitous rale very moist in the inspi-
ration ; bronchial expiration ; dulness in the inferior quarter, in-
creasing as we approach the base.
Nov. 15. The skin is warm; pulse can be counted, 144, very
small, respiration 36, without dilatation of alae nasi ; on the right
back persistence of the same physical signs ; on the left, the sub-
crepitous rale is heard throughout ; diarrhoea still colliquative ;
paleness and emaciation extreme.
16th. In the morning same state, and death supervened in the
evening.
The treatment consisted of julaps of poppies, and a few grains of
diascordiurn; 1 the pernitrate of iron (gutt. vi.) was exhibited for
the diarrhoea; on the I lth, also, a blister was applied to the right
back ; and the appetite being partly preserved, the child took milk
and bouillon.
Autopsy thirty-eight hours after death—weather cold and damp.
Last degree of marasmus; numerous ecchymoses upon trunk
and extremities.
Arachnoid healthy, with considerable serous effusion under-
neath ; pia mater not injected ; three or four spoonfuls of serosity
in the ventricles ; brain normal.
Larynx, trachea, and bronchi are but just tinged with red.
The pleura, smooth and polished, contain neither false mem-
brane nor serosity.
Right lung.— AX the anterior part of the superior lobe there are
seen some projecting, pulmonary lobules ; the vesicles are visible
to the naked eye, and there are also visible some considerable bub-
bles of air in the interlobular cellular tissue. At the summit, be-
hind, a space, the size of a small egg, the parenchyma is red,
friable, and does not float upon water; an incision gives issue to a
yellowish purulent liquid, perfectly analogous to what is evolved
m the bronchi, and which escapes from the little cavities formed
bv their dilatation. The lower lobe is purple externally, upon in-
cision it is a red colour marbled with gray ; is friable, and sinks in
water- in many points there are small cavities anologous to those
of the 'upper lobe; the scissors penetrate easily into the interior, on
incising the bronchi, the mucous membrane of which appears con-
, D iascordium is an electuary comprising a great quantity of ingredients
of tonic, with some sedative properties. — P.
/2 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
tinuous with that uniting the above cavities; the bronchi of this
lobe are of a vivid red, and contain a yellowish purulent liquid.
Left lung. — Upper lobe perfectly healthy ; lower lobe is purple
in its posterior and inferior third ; an incision reveals the existence
of a considerable number of points, varying from the size of a pea
to that of a filbert, red and friable, (lobular pneumonia;) the
bronchi of this part are slightly reddened but not dilated, con-
taining a moderate quantity of spumous liquid. The remainder of
the lobe is healthy.
The pericardium enclosed a spoonful of serosity ; the tissue of
the heart is of good consistence ; the auricles contain some gela-
tinous coagula.
Abdomen. — The mucous membrane of the stomach is thin and
softened in the great curvature.
The mucous membrane of the small intestine is remarkably
white, giving no strips, and its tenacity is extreme.
The large intestine is of a vivid red in various points : its mu-
cous membrane is softened in the red points, and offers a consider-
able number of dilated, follicular orifices.
The liver is pale, yellowish, and greases the knife; the spleen
and kidneys are normal ; no tubercles any where.
Remarks.— We find, in this observation, a type of that variety
of pneumonia which assumes the aspect of chronic disease. As
the pulmonary inflammation commenced under our eyes, we had
the opportunity of following it in all its phases, and appreciating its
duration. It is in a case like this, we have to felicitate ourselves
for our daily and exact auscultation of all our young patients, with-
out which precaution the half of our pneumonias would have
escaped us. The symptoms of reaction were nearly inappreciable ;
the acceleration of the respiration, however, and the results of the
auscultation have clearly indicated the progressive increase of the
disease. The extreme moisture of the subcrepitous rale had made
us suspect a dilatation of the bronchi, and the autopsy confirmed
our supposition.
OBSERVATION IV.
Child of four years. Measles followed by chronic enteritis. Marginal and
lobular pneumonia Dilatation of the bronchi. Complete absence of re
rnat omy PaUClty ° f ^ ™ SC » h ^ ^ explained^ ? paTological
Perrin (Clemence,) tet. four years, entered September 20 and
was placed No. 11, ward St. Anne. ' U ' and
This young patient, of delicate constitution, subject to diarrhrp,
and eruptions upon the hairy scalp, entered for the first lj
September: she was then convalescent of measles of thihti
marks were still present. At this time we disTov-^ f ^
there existed a cough, the respiration to be pure and Une pe^ "^
e
h
ssi on
OBSERVATIONS AND TABLES. 73
resonant. She left the hospital the 14th, to enter again the 20th,
attacked with a diarrhoea which had existed since her departure.
Sept. 21, she was as follows :— Hair chestnut, eyes blue, face
pale, emaciation advanced, constitution delicate ; countenance na-
tural, hps pale, skin not hot ; pulse 96, respiration 32 ; percussion
resonant before and behind; respiratory murmur perfectly pure ;
pulsations of the heart regular, strong, distinct, and heard in the
whole of both backs. A little cough, no expectoration, tongue
moist, a little grayish; appetite still present; abdomen supple ; no
oedema of extremities ; no cerebral symptoms.
Oct. 5. The child complained of pains around the umbilicus,
and some inequalities were felt in the abdomen at this spot. The
following days the cough augmented, and there were heard some
mucous cracklings, especially at the left base, which afterwards
disappeared, leaving the respiration pure. The cough, however,
persisted ; and, Oct. 7, there were heard some bubbles of mucous
rale in the right back : but not only were there no symptioms of
reaction, but the pulse was below the standard; pulse 64; the
hands are cold ; the face extremely pale ; the extremities oedema-
tous, and the diarrhoea persists.
Nov. 3. Same general state. Percussion every where resonant ;
the respiratory murmur is more rude at the right than the left side,
but without rale. The pulse is nearly insensible ; still a little cough.
From the 3d to the 6th November, the day of death, our patient
continued in much the same state, with the diarrhoea still colliqua-
tive : despite of which, however, the appetite was still preserved.
Nov. 4. There are observed some aphthas upon the tongue and
lips; the pulse continuing insensible, the respiration not accele-
rated, the feebleness too great to allow the patient to sit up for aus-
cultation, and she died Nov. 6, at seven P. M.
Autopsy thirty-six hours after death — weather cold and dry.
No cadaveric stiffness ; last degree of marasmus ; oedema of ex-
tremities.
Head. — Fontanella half ossified ; arachnoid smooth, transpa-
rent ; no glands of Pacchioni ; considerable subarachnoid infiltra-
tion of serosity ; the cerebral veins contain no blood ; the cerebral
substance pale, of good consistence, containing three or four
spoonfuls of serosity in the ventricles.
Neck. — Larynx healthy ; trachea and bronchi contain a large
quantity of purulent liquid, but their mucous membrane is healthy.
Chest. — The pleurae are smooth, polished, and contain neither
false membrane nor serosity.
Right lung. — The middle, or small tongue-like portion of the
lower and the lower part of the superior lobes, are purple exter-
nally — penetrable by the finger, upon incision very finely granu-
lated. Pressure causes to exude from the affected parts an infinity
of small drops of a liquid like that in the bronchi, whitish, not
74 RILLIET AND BARTHEZ ON PNEUMONIA OP CHILDREN.
spumous, and lodged in the little cavities formed by the dilatation
of the bronchi, which is so great that their extremities are double
in diameter the parent bronchus. The mucous membrane of the
bronchi receives its coloration from the subjacent tissues. In the
remaining lobes, which appear healthy externally, an incision re-
veals a large number of indurated points, where the pulmonary
tissue is red and friable, (lobular pneumonia.) Their volume va-
ries from a filbert to the head of a large pin. Finally, in a large
number of points, and especially along the anterior border, the pul-
monary tissue is projecting, and presents a kind of thickening,
where the pulmonary vesicles are clearly distinguished, greater in
volume than in other parts of the lung.
Left lung. — The tongue-like portion which is in front of the
heart, and the part of the lung lying upon the diaphragm, in about
an inch of the elevation, present an alteration of the parenchyma
and bronchi similar to that of the right lung. At the summit of the
inferior lobe there is a cavity capable of containing a large filbert,
having its external wall formed by the pleura, and a communication
with a single bronchus, whose mucous membrane appears to be
continued into its interior. The liquid contained in this cavity is
white, not spumous, analogous to that in the smaller bronchi. The
remainder of the parenchyma is healthy, with the exception of
some scattered points of lobular pneumonia.
Neither the lungs nor the bronchial glands contain any trace of
tubercles.
The pericardium encloses a spoonful of serosity ; the heart has
its ordinary volume ; the valves are pale, with some coagula in the
auricles.
Stomach. — Mucous membrane rose coloured in the great curva-
ture ; gives no strips at this part.
Small intestine. — Mucous membrane pale, very thin, affording,
however, strips of two or three lines.
Large intestine. — In the last foot the mucous membrane is
thickened, red, softened, &c.
The mesenteric glands are tuberculous, and many of them
softened.
The other abdominal organs present no appreciable alteration.
No active remedies were employed against the pneumonia; the
diarrhoea was merely combated by enemata of starch and poppies.
Remarks. — Here is another very remarkable example of those
pneumonias of a chronic form, which constitute our first variety.
In this case the pneumonia was not generalised, and the symptoms
of reaction were entirely wanting. As to the auscultation, it o-ave
only negative results, in spile of the existence of the bronchial dila-
tation. But the absence of many of the physical signs may easily
be explained by the nature of the lesions found at the autopsy : 1.
The absence of the bronchial respiration is very well explained by
the slight extent of the pneumonia: if, however, the auscultation
had been as constantly practised in front as behind, we should have
OBSERVATIONS AND TABLES. 75
probably detected it on the level of the middle lobe : 2. The ab-
sence of rale, in the last days, is as easily conceivable, upon reflec-
tion that the purulent fluid filling the bronchi was not penetrated
by air.
If the explanation of the absence of certain signs is easy, it is no
less so to account for those in reality present. Thus, the roughness
of the respiratory murmur in the right back is naturally explained
by the existence of the numerous points of lobular pneumonia
which the autopsy revealed.
OBSERVATION V.
Child of three years. Lobular pneumonia appearing at the same time with
an imperfectly marked measles, in the course of a chronic enteritis.
Pneumonia becoming slowly general. Resolution still more slow. Last
degree of emaciation. Death imminent. Amelioration six weeks after
the commencement. Final recovery. No active treatment.
Brerige, set. three years, was brought to the hospital September 12,
and placed No. 9, ward St. Anne. Very little information as to her
previous health ; but we learned that three weeks before, she was
attacked with fever, cough, and an eruption of red spots over the
whole body, (measles.) Since, she had suffered with diarrhoea and
oedema of the extremities.
Sept. 13th. Constitution frail and delicate ; hair blond, scanty;
eyes blue, impetiginous scabs upon the lips ; upper and lower ex-
tremities cold and purple, with a sensible cedema ; abdomen full,
but no fluctuation; pulse regular, 112, inspirations 22; in both
backs percussion resonant, and respiration perfectly pure ; same in
front ; pulsations of the heart not loud, but distinct; tongue moist;
diarrhoea abundant, like beaten eggs ; thirst great ; the child is
very plaintive.
From Sept. 13th to Nov. 8th, the diarrhoea remained the same;
the emaciation advanced rapidly, but the oedema disappeared almost
entirely. The respiration during all this time remained perfectly
pure, and the percussion resonant. Auscultation had been practised
every day.
Nov. 8th. There supervened three or four vomitings, without
any symptoms of reaction.
9th. the skin is hot; pulse 160, respirations 44, without dilata-
tion of the alse nasi ; slight cough for the first time since entrance;
in the whole of right back subcrepitous rale, with inspiration and
expiration ; on the left the respiration is strong and pure ; per-
cussion every where resonant ; on the thighs, legs, and abdomen
there exist little red irregular papules of the size of the head of a
pin, disappearing under pressure ; no trace of eruption in the rest
of the body ; diarrhoea still abundant.
10th. The eruption has faded, having been confined to the lower
half of the body. The pulse is imperceptible ; respirations 30 ; the
76 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
warmth of the skin has disappeared ; in the right back subcrepitous
rale ; in the left some rare crackles.
11th. The eruption has disappeared ; pulse 130, respirations 36;
same phenomena of auscultation.
1 2th. No change.
13th. Skin warm ; pulse 128, respirations 40 ; in the whole
right back a subcrepitous rale heard at intervals ; no vesicular
expansion at the base ; percussion less resonant relatively to the
opposite side.
14th. Skin warm ; pulse 156, respirations 48, elevating- the
whole thorax, not anxious; slight dilatation of the alas nasi; in
the whole right back subcrepitous rale, in the lower third with
bronchial expiration ; percussion but slightly resonant at the right
base ; respiration pure on the left side.
Until November 25th, there appeared no change, except a con-
tinued increase of the emaciation. The face is extremely pale, the
diarrhoea persists, the symptoms of reaction have disappeared ; the
same subcrepitous rale, dulness, and bronchial expiration in the
right back — but the abundance of the rale frequently overpowers
the bronchial sound.
From Nov. 29 until Dec. 20, the child was examined every day,
and each examination gave very nearly the same results, the sub-
crepitous rale in the right back, dulness in percussion at the base,
but without the bronchial expiration. The emaciation is at the
last degree.
Dec. 20. There exists a little amelioration ; our patient very
cross and plaintive hitherto ; has become more pleasant ; she is
seated in the bed; the countenance is a little better ; the pulse is
116; the appetite has returned; the rale persists, but the dulness
no longer exists.
From Dec. 20 till Jan. 15, the amelioration continually pro-
gressed. The appetite is good, despite the diarrhoea, the tongue
moist, the emaciation commences to disappear and the strength to
return. The rale, however, persisted until Feb. 5, when it entirely
disappeared. The amelioration was not interrupted during the
remainder of the stay at the hospital.
No active treatment was directed against the pneumonia ; some
slight astringents for the diarrhoea (syrup of ratanhia,) some ene-
mata containing a small quantity of laudanum, as well as some
julaps containing syrup of poppies 3iij, were likewise exhibited.
For two days gr. xij. of the white oxide of antimony were added to
the potion of gum. The diet was at no time rigid, as our patient
preserved her appetite throughout the disease.
Remarks. — This observation merits a very particular attention
in consequence of the termination of the disease. The pneumonia
appears under the most unfavourable circumstances at a time when
the child was reduced to the last degree of emaciation and yet
recovery followed. But for the final resolution of the pulmonary
engorgement, how long were we obliged to wait ! The eruption
OBSERVATIONS AND TABLES.
77
occurring at the same time as the pneumonia, appeared to have
more the characters of a simple erythema (erythema simplex) than
of the measles. This opinion is confirmed by the fact that the pa-
tient had already been attacked by the eruptive fever, which rarely
appears twice in the same individual. The form of the pneumonia
places it in our first species ; the concomitant eruption, whatever
its character, appeared to impart to the disease symptoms of more
than usual reaction ; an acceleration both of the pulse and respira-
tion decidedly marked the commencement of the disease. The
results of the auscultation deserve careful meditation, as this single
history furnishes several examples of the different transformations
of the respiratory murmur.
OBSERVATION VI.
Lobular pneumonia supervening in good health, in a child of two years,
accompanied with cerebral symptoms.
Sinet, (Pierre- Victor,) set. 2 years, No. 8, ward St. Thomas,
entered Nov. 11, and died in the night of the 17th and 18th.
This child, born at the full term in perfect health, has, however,
never continued in the enjoyment of it. A few days after birth, he
was attacked with a purulent ophthalmia, to which succeeded an
impetigo of the hairy scalp, followed by frequently repeated colds.
These°different affections so retarded his developement, that at pre-
sent he walks with difficulty, speaks but a few words, and dentition
has commenced only within five months, at which time he had
slight convulsions and a diarrhoea lasting some days.
Nov. 3, being in tolerable health, he was attacked with a violent
cough attended with fever: on the morrow, during twenty-four
hours, he had convulsions lasting from ten minutes to half an hour,
and returning about every hour ; attacking the limbs, face, and
eyes. The cough and fever have persisted since, and the child has
remained pale, bloated, somnolent, without appetite or diarrhoea.
Nov 12. Patient lying on back, face slightly coloured on the
left side the ala3 nasi dilate considerably, the skin is slightly warm,
the left foot is, however, a little colder than the right, and the con-
trary is evident with regard to the hands. Pulse small, frequent,
146 to 150. „ . . wr on . .
The oppression is considerable. Respiration 76 to 80, irregular,
sometimes less, sometimes more in number. The resonance on
nercussion and the respiratory murmur are every where good.
Lios dry, tongue moist, gums a little swelled and red, the incisors
are hardly projecting. Abdomen somewhat large, full of gas, but
supple and not painful ; no diarrhoea. (Infusion of mallows with
honey, calomel gr. vi. emollient enema. Bouillon.)
13 Fever and agitation all night— calomel has produced no de-
iections (same prescription except the calomel.)
14. Night as the former— cough a little hoarse and strong— no
78 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
diarrhoea. The face is pale, lips dry and encrusted ; the patient is
very irritable, crying whenever he is touched and hardly allowing
an examination. 50 irregular inspirations, difficult, with a hard
noisy and painful expiration. Impossible to count the pulse. Aus-
cultation is almost impracticable, nevertheless, despite the cries, we
thought we heard a mucous rale on the right side. (Same prescrip-
tion, calomel gr. vi. laxative enemata.)
15. Some agitation throughout the night, day somnolent, his
sleep is tolerably tranquil, permitting us to count 30 irregular in-
spirations and 114 small pulsations. As soon as he is awakened,
he becomes immediately very irritable, and only a superficial ex-
amination can be made. Our patient is bloated, with his eyes en-
crusted, as also the nose and lips. Abdomen tense and pain-
ful ; one dejection after the calomel ; a slight cough still continues.
(Infusion of mallows with honey. Magnesia gr. 12. Emollient
enema. Bouillon.)
17. Slight stiffness of the upper extremities: the fingers are bent
upon the hand and the hand upon the wrist ; they can be straight-
ened but not without causing pain ; the feet are slightly flexed ; the
sensibility is preserved but slightly diminished equally on both
sides; pupils dilated but movable. The head is quite movable;
these symptoms were not noticed by the attendants prior to the visit.
The face presents sudden alternations of pallor and redness, the
oppression is extreme ; the dilatation of the alae nasi considerable.
There are still the accesses of irritability, even when not touched.
Consciousness is still present, and drinks are swallowed with
avidity. (Mallows, syrup of gum; magnesia, and calomel, aa. gr.
iv. demi emollient enema. Bouillon.)
During the day our patient had well marked convulsions in all
the limbs for about half an hour. At the evening visit he is more
tranquil. Pulse 148, respiration 58, unequal. The head is drawn
backward, but without stiffness ; pupils less dilated ; the limbs are
the same as in the morning ; sensibility the same ; skin hot with
momentary perspirations.
Our patient remained in this tranquil state, in full consciousness,
and asking frequently for drink until the middle of the night, when
he was again taken with convulsions lasting for a short time, and
he died quietly about 5 o'clock.
Autopsy thirty hours after death—weather mild and slightly moist.
The body loaded with fat, presents a slight swelling of the ex-
tremities, which have remained flexed as durino- Hf e . The thorax
presents modosities at the union of the cartilages and ribs.
Brain. — Cranium very voluminous and its walls are very thick
in various points, and thin in others ; the anterior fontanelle is not
ossified. Dura-mater very adherent to the bone but appears healthy.
The arachnoid smooth, transparent, presents a few of Pacchioni's
glands. In the pia mater there is an abundant serous infiltration
without any granulations, or traces of inflammation. The simuses
OBSERVATIONS AND TABLES. 79
contain numerous coagula, some coloured, others discoloured : the
central veins are slightly congested.
The consistence of the cerebral substance is everywhere good.
The cortical portion is slightly rose-coloured, the medullary is only
slightly marked with bloody points upon incision. Ventricles con-
tain three to four spoonfuls of transparent serositv; their walls are
healthy. v y '
The spinal marrow presents no alteration in colour or consis-
tence. There is only remarked rather an abundance of sub-
arachnoid fluid, and an infiltration, more considerable than usual,
between the bones and dura-mater.
Thorax.— The right pleura has some recent adhesions, which
are soft, gelatinous, and infiltrated with a yellow coloured serum.
The lung of the same side does not collapse upon the opening of
the chest.
The whole of the superior lobe hepatised in the second and third
degrees, is gorged with a great quantity of a sanious grayish
liquid. At its external and middle portion there is a little cavity
of the size of a filbert, filled with sanguinolent fluid, not communi-
cating with the bronchi.
The middle and lower lobes are hepatised in the second degree,
nearly throughout, but especially behind and in the upper part :
the tissue is dense red, smooth upon incision, granulated upon
tearing, and easily penetrable by the finger. The anterior part o?
the base alone remains unaffected and floats upon the surface of
water. The healthy portions present some vesicles more volumi-
nous than the others, apparently emphysematous.
The small bronchi appear reddened from the colour of the sub-
jacent tissues, and containing liquid mucus, not bloody.
The left lung and pleura are perfectly healthy, and contain but
very little liquid.
The larynx and the large bronchi are healthy.
There are no tubercles in any of the thoracic organs.
The heart without any alteration, and of good consistence, con-
tains numerous coagula in all its cavities.
Abdomen. — The mucous membrane of the digestive tube pre-
sents no notable alteration. Throughout its whole extent it fur-
nishes strips of five and six lines, except at the great curvature of
the stomach, where the strips are only two or three lines. The
colour is a gray rose, and at intervals there is an injection, but
limited in extent.
The other abdominal organs are in the same heathy state.
Remarks. — This observation is an example of pneumonia ac-
companied with cerebral symptoms ; we observe at the first view.
that the thoracic disease has not been entirely masked by the phe-
nomena of cerebral reaction. The first symptom was cough, with
an oppression, which was always considerable, and these two
symptoms have persisted until death, although they diminished in
intensity, and presented very considerable variations at different
80
RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
times. The auscultation was never properly practised; we are
sure, however, that six days before the death the respiration ap-
peared pure, and nevertheless we found the hepatisation advanced
to the third degree.
It is impossible to believe that so considerable a hepatisation,
should not be revealed by auscultation if properly practised ; we
must only think that there are pneumonias, which, by sympathy
reacting upon the brain, give rise to cerebral symptoms, which,
absorbing the attention of the observer, mask the symptoms of the
thoracic affection.
In the present case, the cerebral symptoms showed themselves at
the beginning and end of the disease and are analogous to those
described by M. Tonnelier, in a memoir in the Gazette Medicate.
The author of this memoir asserts that this assemblage of cerebral
symptoms exists in children, without any lesion of~the nervous
centres, but of different thoracic or abdominal organs.
Finally, to conclude, we must notice the form of the hepatisa-
tion, which is lobar, and occupied only one lung, a fact in direct
opposition with the opinion of Dr. Gerhard, who affirms, in chil-
dren from two to five years, pneumonia to be always double and
lobular in its form. This case, moreover, is not the only one,
which contradicts the assertion of the American pathologist. 1
OBSERVATION VII.
Measles. Lobular pneumonia generalised in the second and third stages.
Mucous rale. Masking for a long time the bronchial respiration. White
softening of the mucous membrane of the large intestine.
Delaforte (Theophila Alexandre), ast. two years and a half
was brought to No. 2, ward St. Thomas, without any other infor-
mation than that he had had the measles six weeks previously and
had been sick ever since.
Upon entrance Nov. 30, we saw him in the following state-
complexion blond, skin fine and pale a little rough and scaly upon
the extremities, giving the sensation of a dry heat, the face is ane-
mic, infiltrated, colour of wax, the nasal line is very pronounced
the eyes are encrusted, the lips dry, sticking together and pale!
ihe alae nasi dilate considerably immediately preceding the in-
spirations, the pulse is small and frequent, impossible to count
lrom the patient's restlessness.
On opening the mouth there are found only the incisors and one
molar ; the gums are neither red, nor swollen, and do not appear
pa.nfu 1; the tongue is moist and pale; the abdomen is large and
soft, although filled with gas, without any tumour ; the live? how-
ever projects a little below the ribs. Pressure especially upon the
right side appears painful, augments the nasal line and causes a
knitting of the eyebrows. Dejections frequent, loose and yellow.
1 See the table of Pathological Anatomy.
OBSERVATIONS AND TABLES. 81
The cough is moist, not frequent ; the chest resounds moderately
well in its whole extent; every where except in the left part and
axilla, there is heard a large abundant mucous rale in both the ex-
piration and inspiration, more abundant at the summit than the
base of the lung. It is fine and subcrepitous in the front of right
base, (white decoction, 1 julep with oxide of antimony 3ss. syrup of
poppies gss. demi emollient enema: bouillon.)
Dec. 1. At first sight our patient appears moribund, he is so pale,
feeble, and nearly motionless. The symptoms, however, are the
same as yesterday, except a slight forward movement of the lower
jaw. The cough is less abundant, the rales still persist. (Same
prescription.)
Dec. 2. Same general aspect. Our patient utters at moments a
singular plaintive cry. Behind, the rale is the more abundant at
the right base ; there is a bronchial expiration in the sub-spinal
fossa and here the percussion is dull. Persistence of the diarrhoea
— pulse small, frequent, cannot be counted — (oxide of antimony,
3j.) Death in the evening of this day.
Autopsy forty-four hours after death — weather cold and dry.
Chest. — The pleurae present old adhesions posteriorly.
Right lung. — Deep red externally, especially posteriorly ; volu-
minous, not collapsing. Its superior lobe upon incision resembling
the liver, is of a yellowish gray and red ; upon scraping it furnishes
a sanguinolent, sanious liquid ; upon tearing, it appears granulated,
and the finger penetrates without difficulty. This lobe sinks in
totality to the bottom of water.
The inferior lobe presents the same characters, with a redder
colour, but only in the posterior portion. It floats only by the an-
terior portion of its base, which however presents some points of
hepatisation. The middle lobe, equally hard and large, presents
some points of hepatisation, and floats in totality. The nodules of
separate engorgement, small in number, vary in size from a pea to
a filbert.
The mucous membrane of the smaller bronchi transmits the
colour of the subjacent tissues : where the bronchi are sufficiently
large to furnish strips, there is neither thickening nor softening.
They contain also a tolerable quantity of mucus.
Lejt lung.— Externally marbled gray and red, but in general
the colour is not deep— it floats in totality and in parts, except a
very small portion of the base which is hepatised. It contains ra-
ther an abundant quantity of a spumous liquid, and is a little less
resistant than a healthy lung.
The small bronchi of this lung are redder than those of the other,
owing to the more vivid redness" of the subjacent tissues; the mu-
cus is" also abundant.
The bronchial glands are small and but slightly developed;
* Principally mucilaginous.— TV.
17__b ril 6
82 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
there are no where any tubercles. The trachea and the large
bronchi are of a grayish red and perfectly healthy.
Abdomen. — Mucous membrane of stomach and small intestines
of a normal colour and thickness, giving strips of from three to
five lines. The patches of Peyer red and' somewhat developed are
neither softened nor ulcerated.
The large intestine is gravely affected : throughout its whole
length, the. mucous membrane of a pale white is very thin and does
not give strips in any of its parts. This intestine is filled with a
yellow mucous substance, in large quantity. The mesenteric glands
are small, numerous, not softened.
The other abdominal organs are normal.
Brain. — No alteration save a somewhat considerable subarach-
noid infiltration. The ventricles contain four to five spoonfuls
of serosity, without softening of the walls. The cortical substance
is slightly rosy, and the medullary presents no bloody points.
Remarks. — This is an observation of lobular pneumonia gene-
ralised, agreeing entirely with our description of the passage of
this pneumonia to the third degree.
It shows that in young children, and in this kind of pneu-
monia especially, the abundance of the rale may mark the patho-
gnomonic signs of the pneumonia itself.
The general state of the patient and the concomitant lesion of
the large intestine permit us to rank this case in our first category;
it must be, however, regretted that the previous history of our pa-
tient was so incomplete, as well as the succession of symptoms
from the commencement.
OBSERVATION VIII.
General and capillary bronchitis. Mamelonated and partial pneumonia.
Hepatisation and carnification, with dilatation of the bronchi.
Fariol, (Jules,) aet. five years, entered ward St. John No. 6, De-
cember 22, 1837, and died January 5, 183S.
We have had but few details of the previous history of this
patient, as his parents had him at home only a month before his
entrance.
At that time he coughed much, had a catching pain in the right
side, but only at the moment of the cough : he was slightly bloated,
had a violent fever, especially at evening, without any diarrhoea.
Since that time, persistence of the fever and couo-h, which has re-
curred in paroxysms, with blowing inspirations* followed by an
abundant serous expectoration, and even vomiting. The pain in
the side disappeared, to return again; the oppression was always
considerable : the appetite was preserved, however, and there was
no diarrhoea.
Present state, (Dec. 23.) Eyes and hair brown ; skin white and
delicate: face a little bloated, especially the upper lip, which is
OBSERVATIONS AND TABLES. 83
pale and encrusted; the nasal line is very pronounced ; the alae
nasi are widely dilated a little before each inspiration. The skin
is moist and warm ; pulse 136, rather small. The tongue is moist
and clean ; the abdomen supple, a little tumid, not painful; two
semi-liquid dejections since yesterday. Respiration difficult, but
regular, 56; the cough manifests itself in paroxysms of hooping,
lasting several minutes. In front, percussion gives a good resonance
on both sides; on the right there is heard a very loud sonorous rale
both in the inspiration and expiration. At the top of the lung, in
addition, there is a prolonged expiration ; on the left, the' same
sonorous rale exists during the inspiration only, while the expira-
tion is very rough and hard, especially at the summit. Behind,
the resonance is good and equal on the two sides: every where
there is heard in the inspiration a mucous, mingled with a sibilant
rale. In the two interscapular spaces, but especially in the left,
there is heard a well-marked bronchial expiration. Very abundant
sero-mucous expectoration. (Mallows, infusion, looch, with oxide
of antimony 3j. ; syrup of cinchona §j. ; soup.)
Dec. 24. General condition much the same ; pulse 140; respira-
tion 60; skin of hands warm and moist, of the body dry and burn-
ing. Behind, the physical signs remain the same. In front, the
sonorous is replaced by a mucous rale on both sides. (Same pre-
scription, oxide of antimony, 3ij., milk.)
25th. Has had a slight sleep in spite of an abundant diarrhoea.
Lips are now a little less swollen; the bloated appearance has
diminished ; the dilatation of the alae nasi is less ; there are no
facial lines, and almost no heat of the skin ; pulse 130, respiration
50, nearly entirely abdominal. Physical signs nearly the same,
except the mucous rale, which is, perhaps, less abundant, and at
the middle of the right side it is more dry and crepitous. The
expiration in the interscapular space is still heard. (Same pre-
scription.)
27th. Skin dry and warm; pulse only 120, soft, full, and regu-
lar; the diarrhoea has ceased; same results from auscultation.
(Same prescription ; oxide of antimony, 3iij.)
28th. The swelling of the nose and lips has reappeared, with the
bloating of the face, and the nasal line. The countenance is pale,
indicating prostration ; skin hot and dry ; pulse 144, soft, tolerably
large : respiration 44 ; tongue moist, rosy coloured, and trembling;
abdomen, although supple, is tympanitic, and generally painful ;
there is an abundant yellow diarrhoea The chest is sonorous ; the
mucous rale, always very abundant, masks a little the bronchial
expiration. Expectoration the same. (Same prescription ; oxide
of antimony, gss. ; semi-enema of flaxseed and poppies.)
29th. The general condition was considerably aggravated ; pulse
146 small; respiration 56; abdomen continues painful, and the
diarrhoea persists. The mucous rale is heard throughout the chest
more abundant than ever; the bronchial expiration has disap-
peared.
84 IULLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
From this time the state of the patient continued to aggravate,
with delirium constant up to the moment of death. From his ob-
stinacy in scratching his nose it was covered with bloody scabs,
and the cheeks became of a violet red. Death, however, did not
arrive till the night of Jan. 4. During these six days, the collapse
and feebleness prevented all careful auscultation : the mucous rale
was always heard quite abundant ; and, in the latter days of life,
there was added the tracheal.
Autopsy thirty-six hours after death — weather cold and damp.
The body is thin, without stiffness, and presents a slight putre-
faction of the abdominal parietes.
Thorax. — The mucous membrane of the trachea and large
bronchi display fine points of a rather vivid redness, and even
appear softened. The right pleura offers solid adhesions, with
some false membranes, which are soft, vascular, and strown with
little tubercular granulations. The lung is heavy, and marbled
red and violet in separate lobules, and floats in totality ; upon inci-
sion, a part of the lobules appear of a clear red, containing air and
a sanguinolent serosity : others, of a deeper colour, are hepatised,
breaking up under the pressure of the finger, and are surrounded by
little collections of miliary tubercles. These collections are scat-
tered through the three lobes, but in small quantities; the same
lung contains also lobules of hepatisation, perfectly isolated one
from the other, which sink in water, and yield, upon pressure, a
sanious fluid not containing air.
At the anterior portion of the middle lobe there is found a portion
of tissue, the size of a nut, collapsed, flaccid, externally of a livid
red, internally a little less deeply so; hard and resistant to the
pressure of the finger, and sinking when thrown into water. The
bronchi of this part preserve the same calibre from their arrival in
this tissue until they reach the surface of the lung ; some even are
a little dilated ; they contain an abundant puriform fluid, and their
mucous membrane, after being washed, is too much softened to
permit of the making of strips.
The smaller bronchi of the other parts of the lung are not dilated,
but are generally reddened, although the subjacent tissue is not
uniformly so; they contain an abundant quantity of mucus filled
with air.
The left pleura offers some weak adhesions : the lung of this side
presents externally clearly marked lobules of a violet colour, pro-
jecting and solid under the finger: upon incision, these portions
appear hepatised and congested, and there issues an abundant sero-
spumous fluid, which is in some parts sanious, and contains air.
The hepatised lobules, being well isolated, sink to the bottom of
water, but considerable attention is necessary to obtain this result
they are so enveloped by, and insensibly confounded with the
simply engorged tissue. These lobules of hepatisation are nume-
OBSERVATIONS AND TABLES. 85
rous, and exist equally in the two lobes. At the anterior portion of
the lower lobe there is found a portion of hepatisation the size of a
filbert, presenting, upon incision, little cavities, the size of a lentil,
communicating with each other by dilated bronchi, and filled with
a puriform liquid ; they are lined by a smooth thin membrane, ap-
parently continuous with that of the bronchi.
The small bronchi of the other parts are like those of the oppo-
site side. In this lunsr there are no tubercles.
The bronchial glands, voluminous on both sides, are tuberculous
on the right ; red," soft, and without tubercles in the left.
All the cavities of the heart contain coagula, both coloured and
the contrary, with a slight quantity of liquid serous blood. The
border of the mitral valve is a little red and thickened; the heart's
volume is not increased.
Abdomen. — No abdominal organ presents any notable alteration :
the mucous membrane of the intestines is every where of a good
consistence, and furnishes strips of five and six lines. The colour
is generally pale, except some arborescent deep redness scattered
in a small extent over the large intestine.
The liver, of the usual size, and containing the usual quantity of
blood, offers a great number of gray demi-transparent granulations
in the interior of its tissue and under the serous membrane.
The spleen contains one crude tubercle of the size of a hemp
seed.
Brain. — Arachnoid smooth, transparent, offering however a
slight opacity about the glands of Pachioni, which are very nume-
rous ; the ventricles contain but little fluid. The cerebral substance
is every where of good consistence and colour.
Remarks. — This observation is of great interest from the nature
of the anatomical lesions, as well as from the results of the auscul-
tation. We find united here examples — 1. Of matnelonated pneu-
monia, that is, lobular pneumonia perfectly circumscribed, without
any tendency to attack the neighbouring portions. 2. Of partial
pneumonia, that is, of lobular pneumonia, with a tendency to the
surrounding tissue. 3. Of limited carnification and hepatisation
surrounding our two species of bronchial dilatation. 4. Of a gene-
ral and capillary bronchitis, proved at the autopsy. All these
lesions were consequent upon the hooping cough.
As for the symptoms from the auscultation, we should remark
that the separate nodules of hepatisation gave a bronchial expira-
tion, which, at the end of the disease, was masked by the mucous
rale,' the result of the constant accumulation of mucus, the conse-
quence, without doubt, of the feebleness of the child.
86 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN-
OBSERVATION IX.
Vesicular bronchitis. Simple lobular pneumonia. Dilatation of the bronchi.
Bronchial expiration masked by the mucous rale.
Androif, (Edmund.) set. nine years, entered Dec. 19, 1837, died
Jan. 2, 1838.
This hoy, of a naturally good constitution and health, was at-
tacked with measles about eight days before his arrival at the hos-
pital, — the eruption having, by report, gone through all its periods;
the fever and the cough continued, with epistaxis, diarrhoea, nau-
sea, pain in the abdomen, and sore throat.
Upon entrance, patient very well developed, not emaciated, is
nevertheless considerably prostrated. The face, livid in spots, is
covered with an abundant furfuraceous desquamation ; the alas
nasi dilate a little, and the edges of the nostrils are surrounded with
red scabs, in consequence of a slight epistaxis ; the lips are dry, not
encrusted, and there is no facial line. The skin is slightly warm
and dry ; pulse 114, large and soft; no cephalalgy ; the tongue is
moist, loaded at the base, red at the tip, and there are some white
patches upon the upper and lower gums. The patient complains
of a slight pain in the region of the larynx ; the tonsils are a little
red and swollen. The abdomen, generally painful, is a little less
so at the umbilicus, and is soft, supple, without gurgling, rose
spots, or eruption, but covered with some furfuraceous scabs. Last
night there was a bilious vomiting, and numerous liquid dejec-
tions.
The respiration is regular, 48 ; the cough moist, frequent, and
still preserving the character peculiar to measles : the expectora-
tion is sero-mucous : decubitus upon the back, but possible upon
either side. The form of the chest, is good, without emaciation, or
an excessive quantity of flesh. In front the resonance is good on
both sides ; on the right there is heard a mucous rale occupying
the whole side, more abundant, drier, and finer in the middle re-
gion, ordinarily heard during both times of the respiration, but
sometimes in the expiration only : on the left, the mucous rale is
less abundant, and sometimes is entirely absent. Behind, the reso-
nance is moderate, but equal in both sides ; in the right, subcre-
pitous rale nearly to the summit, but more especially at the base:
at the summit there is united with it a little prolonged expiration.
The rale exists in the inspiration, and at times there is a sibilant
rale in the expiration. On the left the respiration is strono- and
rude, with an expiration at the summit, and a slight mucous rale in
the whole height of the chest.
(Mallows, syrup of gum, looch with kerrnes, gr. ij. ; semi-emol-
lient enema, sinapisms, bouillon.)
Dec. 21. The prostration and fever are greater; persistence of
the vomiting and diarrhoea ; the chest is in the same state. (Same
prescription ; kermes, gr. iv.)
OBSERVATIONS AND TABLES. 87
Decern. 22. Slight epistaxis ; the face is more purpled, and
asphyxia appears imminent; the prostration is more considerable ;
pulse still 144, but less full, respiration 50: tongue a little pointed,
red at the tip, white at the base; profuse yellow diarrhoea : other
symptoms the same.
The auscultation gives nearly the same results as before, with
only the following differences : Subcrepitous rale in the whole right
back, but finer and drier in different points : there is a little expira-
tion at the summit, where the rale is less : on the left, the rale is
still less at the summit, where is a considerable bronchial expira-
tion ; below there is an abundant mucous rale. (Same prescrip-
tion ; kermes, gr. v.)
Dec. 23. The colour of the face is more vivid ; the prostration
is less, there has been a slight epistaxis ; the nose continues red,
and covered with scabs : the lips are dry, the tongue white and
moist, the abdomen is not painful ; only one dejection since yester-
day ; has taken soup with a relish. Persistence of the febrile re-
action and prostration.
The auscultation continues the same in front, except that the
mucous rale has become subcrepitous in nearly the whole extent,
instead of merely in the middle portion. On both backs, abundant
subcrepitous rale throughout, with strong bronchial respiration at
the left summit, and a slight expiration at the right, in the same
point. (Same prescription ; kermes, gr. vi.)
Dec. 24. Agitation throughout night ; prostration this morning.
The sore throat and diarrhoea have returned. Otherwise, persis-
tence of the same symptoms ; desquamation of cuticle continues ;
(same prescription, kermes gr. vii.)
Dec. 25. Sleeplessness, agitation, and diarrhoea throughout
night. The eyelids are red and encrusted, there is a slight nasal
trait, and the alse nasi dilate considerably. The face is coloured,
especially the left side. The lips are dry, tongue moist, and yellow
at the base ; continual pain in the situation of the larynx, which
does not however embarrass deglutition. The abdomen, slightly
tense and tympanitic, is painful in the epigastrium and right iliac
fossa. Pulse 120, regular, with heat and dryness of the skin. The
oppression continues the same ; same cough, same expectoration.
In the whole of both backs, there is heard a mucous rale, during
both inspiration and expiration ; the bronchial expiration has dis-
appeared. In front, same mucous rale, equally strong on both
sides. (Mallows, syrup of gum, looch, kermes gr. viij. syrup of pop-
pies, gss. semi-emollient enema, bouillon.)
Dec. 27. Prostration extreme, heat of skin. Pulse small, 130.
The cheeks are livid in spots, the nose is encrusted, bleeding, same
physical signs, only the rSle is perhaps a little more fine and sub-
crepitous on the right. The face presents two or three vesicles of
varioloid, none on any other part of the body. (Same prescription,
kermes gr. xi.)
From this time till the day of death on the morning of the second
SS RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
of January, (five days after,) our patient's state was continually
worse and worse, prostration extreme, hardly allowing the sitting
position necessary for the auscultation, which gave always the
same result, mucous or subcrepitous rale wherever possible to place
the ear ; the skin was dry, except during the two or three latter
days, when it was bathed in copious perspirations ; the counte-
nance by degrees lost entirely its expression, the patient could with
difficulty articulate; the pulse was augmented to 160, preserving
the same smallness, and the inspirations to 60; the abdomen con-
tinued painful, and there was an abundant, frothy, yellow diarrhcea.
The same treatment was pursued in carrying the kermes as high
as fifteen grains.
Autopsy thirty-three hours after death — weather moist and warm.
The body presents no stiffness, vibices, nor any trace of putre-
faction.
Thorax. — The right pleura presents some redness and arbo-
rescent vessels without any adhesions.
The right lung heavy, but flaccid and crepitating, collapsing but
little, red posteriorly, of a gray rose colour in front, is gorged with
a quantity of sero-sanguinolent liquid, and penetrated with air.
The incised surface, of a gray rose colour, presents the projection
of the bronchi filled with mucus, together with a number of small
yellow granulations projecting from the surface, about the size of
millet seed and filled with the same mucus ; the tissue of the lung
is more friable than normal, but it still floats upon the surface of
water.
The anterior portion of the middle lobe presents some engorged
nodules, red, hepatised, easily torn and sinking in water; they are
well isolated from the surrounding tissue, which is rose coloured
and have a size from that of a lentil to a large pea.
The small bronchi are red, filled with mucus, and are either aug-
mented, or preserve the same size from their origin to the surface ;
their mucous membrane does not appear softened ; they are also
dilated in all the points where the granulations exist, that is to say,
in nearly all their extent, especially posteriorly.
The left pleura red, and containing some arborescent vessels,
presents posteriorly some gelatinous, soft, and recent adhesions.
The left lung is of a deeper red, swimming in its totality upon
the surface of water, presenting red, projecting spots, scattered un-
equally over its surface. The incision is marbled with a violet and
a clearer shade of red ; the lobules are well defined, and separated
by their colour and projection from the healthy tissue ; the deeper
coloured ones, which are the more projecting, are granulated upon
being torn, easily penetrated by the finger and sink" in water. The
lower lobe presents the same disposition ; the hepatised points how-
ever are smaller and more numerous ; one of them has suppurated
with the formation of a small abscess, which does not however
OBSERVATIONS AND TABLES.
89
communicate with the bronchi. These latter are redder than on
the other lung, but contain less liquid, and are not dilated.
The large bronchi and the larynx, slightly red, contain a small
quantity of liquid mucus penetrated by air.
The bronchial glands are red, voluminous and softened. There
are no tubercles any where.
There is nothing remarkable in the heart or large vessels.
Abdomen. — The stomach contains mucus and some of the
kermes. The mucous membrane is of a vivid red, in large bands
in the smaller curvature, elsewhere in small lines and points with
occasional small ecchymoses ; its thickness appears great, espe-
cially towards the cardiac orifice and the great curvature. Its con-
sistence is variable in points close to each other ; the strips are
sometimes from one to two lines, or from half an inch to an inch,
indiscriminately in the parts which are reddened as in those which
are not so, in the great curvature as in the smaller.
The small intestines present no notable alteration ; the mucous
membrane with a few arborescent vessels at the upper portion is
gray and pale in the greater part of its extent, its thickness is good,
and gives strips from three to five lines; in the duodenum the
strips are only from two to three lines.
At the lower portion there are some reticular patches, similar to
a newly shaved beard, but neither tumid nor ulcerated.
The large intestines are generally healthy, with a good colour
and consistence of the mucous membrane ; the rectum, however,
presents some vivid red spots, where the mucous membrane breaks
under the forceps, giving strips of from two to three lines only.
The mesenteric glands are slightly reddened, but not softened.
The other abdominal organs perfectly normal, are all. however,
except the spleen, gorged with a considerable quantity of blood.
Brain. — Arachnoid, smooth and transparent nearly throughout,
is a little dry, and presents along the grand fissure as well as at the
vermiform process, a considerable quantity of the glands of Pa-
chioni, surrounded with a slight opacity of the membrane.
There is no sub-arachnoid infiltration, but all the small vessels
of the pia mater are distended with blood, and there are even some
small ecchymoses, which the scalpel moved over the surface does
not push before it.
The cerebral veins and the sinuses contain much blood. The
cortical substance presents a little redness, and the medullary
a considerable number of bloody points. The consistence is every
where good, and the ventricles contain from one to two spoonfuls
ofserosity. %
This observation is important as proving the truth oi many ot
our ideas already emitted. We find first a well marked simple
lobular pneumonia, in a child more than six years of age ; we see
besides an abscess of the lung, a vesicular pneumonia and dilata-
tion of the bronchi. The first of these four lesions is so perfectly
distinct from the others, that the symptoms appertaining to each
90 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
may be perfectly appreciated. And finally we observe a com-
mencement of pleurisy with simple lobular pneumonia.
The whole of this disease has been developed after a measles,
the desquamation of which we have been able to see.
The lobular pneumonia was manifested by the characters which
we have attributed to it. In the right front, a drier and finer rale,
surrounded by one coarser and more moist, which finally entirely
prevailed over the former ; on the left back, bronchial expiration at
the summit, mucous or subcrepitous rale every where else, finishing
by masking' the parenchymatous element, in proportion as the
strength of our patient declined.
We must now explain the existence of the same expiration at
the summit of the right back, where the autopsy has not revealed
the existence of a hepatisation ; first, however, we must remark
that perhaps there really did exist one of those lobular pneumonias
at the third degree, which so easily escape detection at the autopsy,
the existence of which may be expected here from the physical
signs. Unless this be the case, why this remarkable discordance
between the lesions? The tissue, more penetrable than usual,
floats nevertheless in water, and its colour is a gray rose ; if we had
examined more closely, perhaps, we should have found the vesicular
granulations surrounded by points of pneumonia at the third
degree.
But even if this explanation be rejected, another may still be
found in the dilatation of the bronchi : we know, in fact, from other
observations, that this alteration may, in certain cases, produce the
symptoms for which we are endeavouring to account. Finally, it
must be noticed, that here, as in the other lung, the bronchial
sound was marked by the mucous rales increasing with the accu-
mulation of mucus in the bronchi.
The symptoms of hepatisation were manifested in the upper part
of the lung, and only during the time when the mucous rale was
least abundant, a fact which proves that a mucous rale may mask
the bronchial respiration, almost immediately, or from one day to
another.
We have spoken elsewhere of the result of treatment.
OBSERVATION X.
Generalised lobular pneumonia at the first and second degree. Dilatation
of the bronchi into small cavities.
Fifrelin, (Joseph-Francois,) a3t. 2 years, entered at No. 8, of the
ward St. Thomas, the 29th and died the 3lst of October.
His father, (a German) speaks no French. Any history therefore
of the previous health or of the commencement of the present dis-
ease is entirely out of the question.
Oct. 30. This child, of a dark complexion, and very little de-
veloped, has so small a pulse as hardly to allow of its being counted.
OBSERVATIONS AND TABLES. 91
There is, however, no febrile reaction, and the patient is cold and
pale. The alae nasi do not dilate, the respiration is oppressed, 40,
unequal, with at times an appearance of stoppage and difficulty in
the expiration, which is noisy and painful in the commencement.
No cough.
Resonance of the chest every where good except in the two lower
thirds of the left back, where it is diminished. Here is heard a
very fine crepitous rale, very abundant, without any bronchial
character. Same in the axilla of this side. Right back coarse
mucous rale not abundant, existence of the same in the two fronts.
The lips are dry, encrusted and cracked; the tongue is moist
and of a rose colour ; the nose is encrusted ; the abdomen is soft,
flaccid, and does not appear painful ; diarrhoea very slight.
Oct. 31. Our patient is moribund and will not permit an ex-
amination ; no cough ; 58 to 60 inspirations ; same aspect as yes-
terday. The crepitous rale of the left side is more abundant, and
very well marked. Mucous rale on the opposite side ; diarrhoea
slight ; death the same day, two hours after this examination.
Autopsy twenty-eight hours after death— weather cold and damp.
Left pleura healthy.
Left lung, the lobules of which are very well marked, but the
vesicles of which do not appear dilated, presents along its posterior
border large and flattened bullae, formed by the pleura solely, and
having the appearance of interlobular emphysema. Upon incision
of these there exude small drops of grayish mucus, not containing
air, puriform, and issuing from little round cavities, the size ot a
lentil. These cavities communicate with the bronchi of which
they are the continuation. Some exist at the surface of the lung
and correspond to the bullae already mentioned ; others in the in-
terior of the lobe are so closely situated as to form a species of cel-
lular tissue being only separated in some cases by an imperfect
partition : others are united by tubes of communication, apparently
dilated bronchi, and which give off numerous branches, themselves
dilated. All these are filled with the same fluid as the little cavi-
ties. Their mucus membrane, not thickened, but coloured red by
the subjacent tissues, is smooth, polished and continuous with that
lining the cavities. At the extremity of one of the bronchi there
exists a tubercle, situated apparently in the very interior of the
bronchus. .
The surrounding pulmonary tissue is easily torn, and is gene-
rally red, some parts of it float upon the surface while others sink
to the bottom, without any apparent difference of their physical
qualities. .
This description applies to the whole extent ot the lower lobe.
The upper lobe presents some projections due to the interlobular
emphysema ; there are none of the little cavities internally and the
pulmonary tissue is slightly engorged.
92 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
The mucous membrane of the larger bronchi, of a slightly vivid
red, possesses a good consistence.
The right pleura presents some rather finer and solid adhesions.
The right lung, generally crepitating, but slightly reddened, pre-
sents, in the middle of its inferior lobe, two nodules of hepatisation
of the size of a filbert, in the middle of which are two cavities per-
fectly similar to those of the opposite side.
All the other small bronchi, not dilated, contain mucus perfectly
penetrated by air.
The subject was taken from us before we could possibly examine
the other organs.
Remarks. — Although this observation is doubly incomplete,
from the want both of the anticedents of the history, and the re-
mains of the autopsy, we cannot help inserting it from the import-
ance of the details above mentioned. Besides every thing directly
relating to the pneumonia is complete both in the pathological
anatomy and auscultation.
We see here a remarkable example of our two kinds of bronchial
dilatation, and which appear to be seated either in the course, or in
the extremities of these tubes.
We can establish the difference between these cavities and the
small pulmonary abscess. Around the bronchial dilatation there is
found a lobular pneumonia on the point of becoming general, the
hepafised portions being already united by an engorged tissue: the
only difference between the portions of the left lower lobe lies in
the circumstance that some of them float on the surface, while
others sink to the bottom of water — in both c.ises there was the
same colour, and the same friability: there existed here evidently a
combination of points of pneumonia in the first and second degree.
This opinion, moreover, is confirmed by the lobular pneumonia of
the opposite lobe.
The symptoms arc not less remarkable : we have, however, but
a few words to say upon these, having already strongly insisted
upon them in the course of the observation. This child," aged only
two years, has presented a well-marked example of crepitous rale.
The existence of this rale appears somewhat contrary to the
lesions which we have found after death, but we find a ready ex-
planation in the fact that the bronchial* mucus was not penetrated
by air, and, therefore, could not give to the ear the sensation of
bursting bubbles. In these circumstances the inflammation of the
lung was manifested by physical signs, belonging to the degree of
the disease.
OBSERVATIONS AND TABLES.
OBSERVATION XI.
93
Lobular pneumonia after measles. Numerous abscesses of the lung. Double
pleurisy.
Lefevre, (Antoine,) oet. four years, entered Oct. 2, No. 35, ward
S:. Jean. Mother healthy ; the father, within three months, has
considerahly emaciated under a cough, haemoptysis, and night
sweats. Nursed by his mother, this child was weaned at four and
n half months ; has never had any cutaneous disease, nor swelling
of the glands : first dentition was easy. Had the small-pox eigh-
teen months, and the measles two months since : this last was fol-
lowed by cough and expectoration ; has been in bed for fifteen
days, and has much emaciated ; the appetite has been preserved,
and there has never existed any complication of intestinal dis-
order.
Oct. 3. Hair blond, emaciation extreme, face pale and a little
bloated, marked by the small-pox ; skin hot and moist ; pulse 120,
small, with some softness : the tongue is clean, the abdomen simple,
and not painful ; thirst, some appetite, slight diarrhoea ; oppression,
slight dilatation of alas nasi ; 46 regular inspirations; cough slight,
not abundant, loose ; expectoration sero-mucous.
Behind, good resonance at the upper part of both chests, dimi-
nishing sensibly at the lower part, but descending a little lower at
the right than left.
Behind, mucous rale in the whole of both lungs, existing in both
times of the respiration — sometimes, however, in the expiration
solely, intermingled with sibilant rale ; bronchial respiration, espe-
cially in all the lower portion, and slightly in the interscapular
space. On both sides, in front, resonance good and equal ; coarse
mucous rale, mingled with the sibilant, in the whole front chest.
(Mallows, syrup of gum, looch, oxide of antimony 3j., semi-
emollient enema ; bouillon.)
Oct. 4. Pulse 150, respiration 50 ; no diarrhoea. The physical
signs vary only as follows : Right back, no bronchial respiration,
except in the middle portion ; elsewhere, mucous rale more abundant
at the base. In left front sibilant rale at the summit, mucous rale
at the base : at the right summit respiration rude, with but little
sibilant or mucous rale. (Same prescription : oxide of antimony,
3iss.)
Oct. 5. Same state ; (oxide, 3ij.)
Oct. 6. Sensible amelioration ; pulse 120, respiration 44 ; sub-
crepitous rale small in quantity in both backs, a little more in the
rio-ht ; resonance and percussion good, and equal on both sides.
In front, a little mucous rale on both sides, especially at the base
of the lungs.
Three liquid dejections; no abdominal pains; appetite. Same
condition during two days. (Oxide of antimony, 3j. ; soup.)
94 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
Oct. 9. Prostration, diarrhoea, loss of appetite; pulse 150, small;
respiration 48.
Right back, dulness on percussion in middle portion, with cre-
pitous rale and bronchial respiration. Below, and to the outside, mu-
cous and unequal crackling ; at the summit, some mucous bubbles
at intervals.
On the left side, less resonance on percussion at the base, ex-
tending round to the side. Rather large mucous rale, with a slight
expiration at intervals.
This falling off, however, was not followed by any long-continued
reaction. (White decoction, syrup of poppies, §ss.)
Oct. 12. Fever slight; pulse 96, respiration 34; tongue clean,
diarrhoea less : the amelioration in the local symptoms, however,
not great.
In the right back the resonance is returned in a slight degree,
but there is still a persistence of the crepitous rale and the bron-
chial respiration : at the top of the same side there exists a slight
prolonged expiration, with a rather abundant mucous rale after
cough.
On the left, at the summit, the respiration is strong : at the base
it is obscure, without rale ; dulness on percussion the same. In
front, respiration pure. (Oxide of antimony, 3iss.)
Oct. 18. The disease has continued stationary up to this time :
the diarrhoea is a little less, but the cough is increased ; paleness
and prostration : the flies commence to gather about the nose, eyes,
and mouth ; skin hot ; pulse 150, with an intermitting stroke ;
respiration 56; oppressed, thirst excessive.
Continuance of the dulness on left back, from the angle of sca-
pula downwards, with subcrepitous rale and bronchial respiration,
under and to the outside of the angle of the scapula: at the summit,
mucous rale at intervals.
On the right side, same state as before. In front, respiration pure
on both sides.
Same prescription.
Oct. 19. Notable aggravation of local symptoms. On the left, the
flatness extends to the top of interscapular region. In the whole
extent of this there is bronchial respiration and subcrepitous rale :
at the base the rale is drier and more crepitous : at the base of right
back little resonance upon percussion, with subcrepitous rale and
bronchial respiration. At the summit, mucous rale, both in the in-
spiration and expiration, disappearing after cough, whilst, on the
contrary, all the other rales are augmented by it. In front verv
abundant mucous rale throughout the right side, especially under
the clavicle. (Oxide of antimony, 3ij.)
Oct. 20. Severe pain under right nipple; and there are heard at
this point explosions of a subcrepitous rale during both the inspira-
tion and expiration. Further than this, same local conditions as
yesterday ; skin warm ; prostration more considerable.
Oct. 21. The pain of the side has diminished. Behind the dul-
OBSERVATIONS AND TABLES. 95
ness continues, but there appears more respiratory sound, unless it
may be that we hear a very distant bronchial respiration. At the
summit some mucous bubbles.
Oct. 22. Oppression extreme, respiration 66, dilatation of ala?
nasi considerable ; pulse 150, small, hurried, a little irregular ;
thirst excessive.
The left side appears still a little painful. On this side, behind,
under the axilla, and even in front, the dulness on percussion is
considerable. The respiration is inaudible in the whole lower part;
heard only at the summit behind, and there it is bronchial : persist-
ence of the same symptoms in the right side.
Oct. 23. Death at 8, A. M.
Autopsy thirty-two hours after death — weather cold and moist.
Emaciation extreme, with flaccidity of the flesh ; no stiffness, no
vibices ; putrefaction somewhat advanced upon the abdomen.
Chest. — The left pleura — rilled with an immense quantity of
a serous liquid, containing floating flocculent albumen, lined in
some parts with soft and not thick false membranes — is in itself red
and injected. The left lung, compressed upon the vertebral column,
is red and solid, and sinks immediately in water. On incision it is
smooth and red, and presents the projecting orifices of a number of
bronchi. The texture, granular when torn, is easily penetrable
by the finger, but rather less so than in the usual hepatisation, due,
without doubt, to the compression by the effused liquid.
In its interior are discovered a great quantity of small cavities,
varying in size from that of a hemp-seed to a large pea, and filled
with pus, mixed with coagula of blood. Some of these cavities
communicate with the bronchi, the opening of which are easily
distinguishable. At the point where the bronchus opens into the
cavity, the mucous membrane appears cut short off, and presents a
visible solution of continuity, which may, in some instances, be de-
monstrated by the formation of strips. These bronchi, slightly
reddened in fine points, and containing a little spumous mucus, do
not appear dilated : a considerable number of these cavities do not
communicate with the bronchi, but appear rather surrounded by
them. These abscesses, so numerous that no attempt was made to
count them, do not communicate one with another.
No tubercle any where in this lung.
The ritrht pleura presents the same alterations as the left, except
that it contains only a few spoonfuls of serosity.
The right lung, not solid like the left, floats in totality upon the
surface of water. The finger, passed over its surface, detects small
hard bodies, which answer to engorged portions of a deep red, of
the same size and form as the abscesses of the opposite side. These
portions are solid, and easily broken down under the finger : they
sink also to the bottom of water, provided they be properly isolated
from the surrounding tissues. Some of these points of pneumonia
96 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
are traversed by bronchi, which do not change their natural aspect.
The bronchi generally exhibit a small number of red points in
their mucous membrane, and are filled with a spumous mucus.
The surrounding tissue, red upon incision, abundantly gorged
with blood and a spumous serosity, floats upon the surface of water,
and does not break under the pressure of the finger.
A small part of the base of the inferior lobe is reddened, filled
with a sanious fluid, breaks down under the finger, and sinks to
the bottom of water ; the remainder of this lobe, containing no
hepatised portions, is merely much engorged.
No tubercles.
The bronchial glands, large, red, and softened, are not in the
least tuberculous.
The heart, filled with coagula, some coloured and others the
contrary, presents nothing but a hard and thickened adhesion of
the aortic valves, which prevents their application against the
aorta.
Abdomen. — The mucous membrane of the stomach, containing
a few arborescent vessels, is, however, normal in its thickness, and
affords strips of several lines.
The mucous membrane of the small intestines, of a gray rose
colour, is healthy, and presents at its inferior porlion some nume-
rous reticulated patches, slightly thickened, but not softened.
The mucous membrane of the colon generally of a rosy red,
slightly thickened, furnishes no strips.
The liver of a normal size is generally red, hut the two sub-
stances are distinct.
The kidneys contain much blood, but are healthy. The bladder
contains urine which is troubled and deposits a sediment.
The pancreas are red and gorged with blood.
The spleen, not congested is of its usual size.
The peritoneum is of a rose colour, the subperitoneal vessels are
gorged with blood ; in a word, all the abdominal organs except the
spleen contain a considerable quantity of liquid black blood.
Brain. — The dura mater, very thick, is adherent at the anterior
fontanelle which is ossified. The arachnoid slightly opaque along
the longitudinal fissure, presents a large number of Pachioni's
glands, disposed in groups : there are some of these also along the
superior vermiform process. The cerebral veins are distended
with blood and the superior longitudinal sinus contains a firm
coagulum. The pia mater is infiltrated with a moderate quantity
of serosity. The ventricles not dilated contain very little serum.
The cerebral substance is generally soft. The fornix is sensibly
softened as also the tubercular quadrigemina upon their surface
and the anterior peduncles. All these softened parts are white!
The medullary substance presents but few red points, the corticai
is generally rose coloured.
In no organ were there found any tubercles.
Remarks.— The first impression from the reading of this obser-
OBSERVATIONS AND TABLES.
97
vation, is that our patient was attacked with a general tuberculisa-
tion ; for it is precisely in similar circumstances that this lesion is
found in children. We have already spoken of the diagnosis in a
case of this kind. But instead of tubercles, we find a lesion much
more remarkable for its rarity : viz. abscess of the lung. We have
already spoken sufficiently of this termination of lobular pneumonia
not to be obliged to return to it.
In this case the lobular pneumonia of the right side was mani-
fested by the bronchial expiration at the summit of the lung, and
this symptom was finally masked by the mucous rtle. The alter-
nations of abundance and rarity presented by this rale, explain the
irregularity of the other physical signs ; we must, however, admit
the existence at one time of a more extensive pneumonia of the
right side terminating in resolution ; the bronchial respiration and
the dulness upon percussion recognised at the commencement, the
engorged state of the lung at the autopsy after the disappearance of
these physical signs are proof of this. Finally, in this same right
side there was developed a grave pleurisy, although there had only
existed in this lung a lobular pneumonia.
98 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
PATHOLOGICAL ANATOMY.
FIRST TABLE.
Relative frequency of the different species of Pneumonia at the
different ages. 43 autopsies.
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OBSERVATIONS AND TABLES.
99
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Several very interesting consequences may be deduced from
these tables :
1. Vesicular bronchitis does not exist in the simple state.
2. The lobular pneumonias free from all complication are very
rare.
100 RILLIET AND BARTHEZ ON PNEUMONIA OF CHILDREN.
3. From eighteen months to five years the most frequent pneu-
monias are the simple and generalised lobular ones.
4. Under this form the pneumonia is always double; conse-
quently it is the form of the disease rather than the age of the
patient, which makes it double or simple. In proof of this, the
lobular pneumonias which are far from rare between two and five
years, ordinarily occupy only a single lung.
5. After the age of five years the lobular pneumonias are rare.
6. In the idiopathic pneumonias, the right lung is the most usu-
ally inflamed : it is not the same in pneumonias complicating other
diseases.
7. The lobar hepatisations are more frequent in the lower lobes.
8. Carnification is a frequent lesion : we have never met with
it after seven years. It exists rarely uncomplicated.
9. Bronchial dilatation is seldom met with after the age of five
years. Very rare in the uncombined state. And is found indif-
ferently in all parts of the lung.
CONTENTS
\
O NT
PAGE.
History, 5
Pathological Anatomy, . 8
Modifications of the respiratory sound, ........ 23
The connection between the auscultation and pathological anatomy, . . 28
Causes, .............. 34
Rational Symptoms, ........... 39
Sketch of the disease, its progress, &c. ........ 45
Diagnosis, ....... ...... 48
Prognosis, ........ ... ... 51
Treatment, 53
Observations and Tables, ........... 65
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